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ARKANSAS UNITED METHODIST

EMPLOYEE BENEFIT PLAN

PLAN DOCUMENT

(January 1, 2012)

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TABLE OF CONTENTSSUMMARY PLAN DESCRIPTION 9

SCHEDULE OF BENEFITS...........................................................................................11Medical Benefits For Covered Members Who DO NOT Have This Plan As A Supplement To Medicare........11Routine Vision Benefits For All Covered Participants.........................................................................................14

Dental Benefits For All Covered Participants………...……...……………………………………………………14 Prescription Drug Program For All Covered Participants...................................................................................15

Medical Benefits -- Retired Participants...............................................................................................................16Medical Benefits For Covered Members Who DO Have This Plan As A Supplement To Medicare:................18

PREFERRED PROVIDER OR NONPREFERRED PROVIDER....................................21Preferred Providers...............................................................................................................................................21NonPreferred Providers.........................................................................................................................................21Exceptions.............................................................................................................................................................21Exceptions Only Applicable to CVS Caremark Specialty Pharmacy Program....................................................22

MEDICAL EXPENSE BENEFIT.....................................................................................23Copay....................................................................................................................................................................23Deductibles............................................................................................................................................................23Coinsurance...........................................................................................................................................................24Out-of-Pocket Expense Limit...............................................................................................................................24Maximum Benefit.................................................................................................................................................25Hospital/Ambulatory Surgical Facility.................................................................................................................25Emergency Services/Emergency Room Services.................................................................................................26Facility Providers..................................................................................................................................................26Ambulance Services..............................................................................................................................................26Physician Services.................................................................................................................................................26Second Surgical Opinion......................................................................................................................................27Diagnostic Services and Supplies.........................................................................................................................27Transplant..............................................................................................................................................................27Pregnancy..............................................................................................................................................................28Birthing Center......................................................................................................................................................29Sterilization...........................................................................................................................................................29Well Newborn Care..............................................................................................................................................29Children’s Immunizations.....................................................................................................................................30Routine Examination/ Wellness Benefits..............................................................................................................30Therapy Services...................................................................................................................................................31Extended Care Facility..........................................................................................................................................31Home Health Care.................................................................................................................................................32Hospice Care.........................................................................................................................................................32Durable Medical Equipment.................................................................................................................................33Prostheses..............................................................................................................................................................33Orthotics................................................................................................................................................................33Dental Services.....................................................................................................................................................34Temporomandibular Joint Dysfunction................................................................................................................34Special Equipment and Supplies...........................................................................................................................34

Cosmetic Surgery..................................................................................................................................................35Mastectomy...........................................................................................................................................................35Mental and Nervous Disorders.............................................................................................................................35Chemical Dependency..........................................................................................................................................36Prescription Drugs.................................................................................................................................................36CVS Caremark Specialty Pharmacy Program......................................................................................................36Off-Label Drug Usage/Phase III Clinical Trials...................................................................................................36Podiatry Services...................................................................................................................................................37Private Duty Nursing............................................................................................................................................37Chiropractic Care..................................................................................................................................................37Patient Education..................................................................................................................................................37Surcharges.............................................................................................................................................................37Routine Vision......................................................................................................................................................37

MEDICAL EXCLUSIONS....................................................................................................................................37

PRESCRIPTION DRUG PROGRAM.............................................................................41Retail Prescription Drug Deductible.....................................................................................................................41

Individual Deductible For Retail Prescriptions....................................................................................................41Pharmacy Option...................................................................................................................................................41Pharmacy Option Copay.......................................................................................................................................41Mail Order Option.................................................................................................................................................41Mail Order Option Copay.....................................................................................................................................41Covered Prescription Drugs..................................................................................................................................42Limits To This Benefit..........................................................................................................................................42

EXPENSES NOT COVERED...............................................................................................................................42

CVS CAREMARK SPECIALTY PHARMACY PROGRAM...........................................43Notice Of Authorized Representative...................................................................................................................44Appealing A Denied Post-Service Prescription Drug Claim................................................................................44Notice Of Benefit Determination On A Post-Service Prescription Drug Claim Appeal......................................45

DENTAL EXPENSE BENEFIT......................................................................................47Predetermination of Benefits................................................................................................................................47Deductible.............................................................................................................................................................47Coinsurance...........................................................................................................................................................47Maximum Benefits................................................................................................................................................47Alternative Treatment...........................................................................................................................................48Dental Incurred Date.............................................................................................................................................48Covered Dental Expenses.....................................................................................................................................48

Class I—Diagnostic And Preventive Dental Services Limitations and Exclusions...........................................49

Class II—Basic Dental Services Limitations and Exclusions............................................................................499

General Dental Limitations and Exclusions.........................................................................................................50

VISION EXPENSE BENEFIT.........................................................................................52Covered Vision Expenses.....................................................................................................................................52

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VISION EXCLUSIONS.........................................................................................................................................52

PLAN EXCLUSIONS.....................................................................................................53

ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE...............................................55Employee Eligibility.............................................................................................................................................55Employee Enrollment...........................................................................................................................................55Employee(s) Effective Date..................................................................................................................................55Dependent(s) Eligibility........................................................................................................................................55Dependent Enrollment..........................................................................................................................................56Dependent(s) Effective Date.................................................................................................................................57Special Enrollment Period (Other Coverage).......................................................................................................57Special Enrollment Period (Dependent Acquisition)............................................................................................58Special Enrollment Period (Children's Health Insurance Program (CHIP) Reauthorization Act of 2009)..............58Special Enrollment Period (Patient Protection And Affordable Care Act)...........................................................59Open Enrollment...................................................................................................................................................59

PRE-EXISTING CONDITIONS......................................................................................61

TERMINATION OF COVERAGE...................................................................................62Termination of Employee Coverage.....................................................................................................................62Termination of Dependent(s) Coverage................................................................................................................62Leave of Absence..................................................................................................................................................62Layoff....................................................................................................................................................................62Family And Medical Leave Act............................................................................................................................63Employee Reinstatement.......................................................................................................................................63Certificates of Coverage........................................................................................................................................64

CONTINUATION OF COVERAGE................................................................................65Qualifying Events.................................................................................................................................................65Notification Requirements....................................................................................................................................65Cost Of Coverage..................................................................................................................................................66When Continuation Coverage Begins...................................................................................................................67Family Members Acquired During Continuation.................................................................................................67Extension Of Continuation Coverage...................................................................................................................67End Of Continuation.............................................................................................................................................68Special Rules Regarding Notices..........................................................................................................................69Pre-Existing Conditions........................................................................................................................................70Military Mobilization............................................................................................................................................70Plan Contact Information......................................................................................................................................70Address Changes...................................................................................................................................................70

MEDICAL/VISION CLAIM FILING PROCEDURE.........................................................71

POST-SERVICE CLAIMS PROCEDURE......................................................................71Filing a Claim........................................................................................................................................................71Notice of Authorized Representative....................................................................................................................72Notice of Claim.....................................................................................................................................................72

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Timeframe for Benefit Determination..................................................................................................................72Notice of Benefit Denial.......................................................................................................................................72Notice of Benefit Determination on Appeal.........................................................................................................73Foreign Claims......................................................................................................................................................74

FOR PRE-SERVICE CLAIMS........................................................................................74Health Care Management......................................................................................................................................74Filing a Pre-Certification Claim............................................................................................................................74Notice of Authorized Representative....................................................................................................................75Timeframe for Pre-Service Claim Determination.................................................................................................75Concurrent Care Claims........................................................................................................................................76Notice of Pre-Service Denial................................................................................................................................76Appealing a Denied Pre-Service Claim................................................................................................................77Notice of Pre-service Determination on Appeal...................................................................................................77Case Management.................................................................................................................................................78

DENTAL CLAIM FILING PROCEDURE........................................................................79Filing Claims/Participating Dentists.....................................................................................................................79Filing Claims/Non-Participating Dentists.............................................................................................................79Processing the Claim.............................................................................................................................................79Initial Claim Determination..................................................................................................................................80Appeal of Denied Claim.......................................................................................................................................80

COORDINATION OF BENEFITS..................................................................................82Definitions Applicable to this Provision...............................................................................................................82Effect on Benefits..................................................................................................................................................83Order of Benefit Determination............................................................................................................................83Coordination With Medicare................................................................................................................................84Limitations on Payments.......................................................................................................................................85Right to Receive and Release Necessary Information..........................................................................................85Facility of Benefit Payment..................................................................................................................................85Automobile Accident Benefits..............................................................................................................................85

SUBROGATION/REIMBURSEMENT............................................................................87

GENERAL PROVISIONS..............................................................................................89Administration of the Plan....................................................................................................................................89Assignment............................................................................................................................................................89Benefits not Transferable......................................................................................................................................89Clerical Error.........................................................................................................................................................89Conformity with Statute(s)....................................................................................................................................90Effective Date of the Plan.....................................................................................................................................90Free Choice of Hospital and Physician.................................................................................................................90Free Choice of Dentist..........................................................................................................................................90Incapacity..............................................................................................................................................................91Incontestability......................................................................................................................................................91Legal Actions........................................................................................................................................................91Limits on Liability................................................................................................................................................91Lost Distributees...................................................................................................................................................91

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Medicaid Eligibility and Assignment of Rights....................................................................................................91Physical Examinations Required by the Plan........................................................................................................92Dental Clinical Examinations...............................................................................................................................92Plan is not a Contract............................................................................................................................................92Plan Modification and Amendment......................................................................................................................92Plan Termination...................................................................................................................................................92Pronouns................................................................................................................................................................92Recovery for Overpayment...................................................................................................................................92Status Change........................................................................................................................................................93Time Effective.......................................................................................................................................................93Workers’ Compensation not Affected..................................................................................................................93

HIPAA PRIVACY...........................................................................................................94Disclosure By Plan To Plan Sponsor....................................................................................................................94Use And Disclosure By Plan Sponsor...................................................................................................................94Obligations Of Plan Sponsor.................................................................................................................................94Exceptions.............................................................................................................................................................95

Definitions...................................................................................................................... 96

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ADOPTION

Arkansas United Methodist Conferences has caused this Arkansas United Methodist Conferences Employee Benefit Plan (Plan) to take effect as of the first day of January 1, 2012 at Little Rock, Arkansas. This is a revision of the Plan previously adopted August 1, 1995. I have read the document herein and certify the document reflects the terms and conditions of the employee welfare benefit plan as established by Arkansas United Methodist Conferences.

BY: DATE: _____________________

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GRANDFATHERED STATUS DISCLOSURE

This Arkansas United Methodist Conference Plan believes this Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that this Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator.

Covered persons may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.

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http://www.healthreform.gov/

SUMMARY PLAN DESCRIPTION

Name of Plan:

Arkansas United Methodist Conferences Employee Benefit Plan

Name, Address and Phone Number of Employer/Plan Sponsor:

Arkansas United Methodist ConferencesP.O. Box 3611800 Daisy Bates DriveLittle Rock, AR 72203501-324-8003 or 501-324-8040

Employer Identification Number:

71-6163137

Group Number:

ARMET01

Type of Plan:

Welfare Benefit Plan: medical, dental and vision benefits

Type of Administration:

Contract administration: The processing of claims for benefits under the terms of the Plan is provided through a company contracted by the employer and shall hereinafter be referred to as the claims processor.

Name, Address and Phone Number of Plan Administrator, Fiduciary, and Agent for Service of Legal Process:

Arkansas United Methodist ConferencesP.O. Box 3611800 Daisy Bates DriveLittle Rock, AR 72203501-324-8003 or 501-324-8040

Legal process may be served upon the plan administrator.

Eligibility Requirements:

For detailed information regarding a person's eligibility to participate in the Plan, refer to the following sections:EligibilityEnrollmentEffective Date of Coverage

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For detailed information regarding a person being ineligible for benefits through reaching maximum benefit levels, pre-existing conditions, termination of coverage or Plan Exclusions, refer to the following sections:

Schedule of BenefitsEffective Date of Coverage, Pre-existing ConditionsTermination of CoveragePlan Exclusions

Source of Plan Contributions:

Contributions for Plan expenses are obtained from the employer and from the covered employees. The employer evaluates the costs of the Plan based on projected Plan expenses and determines the amount to be contributed by the employer and the amount to be contributed by the covered employees.

Funding Method:

The employer pays Plan benefits and administration expenses directly from general assets. Contributions received from covered persons are used to cover Plan costs and are expended immediately.

Ending Date of Plan Year:

July 31st

Procedures for Filing Claims:

For detailed information on how to submit a claim for benefits, or how to file an appeal on a processed claim, refer to the section entitled, Medical/Dental/Vision Claim Filing Procedure.

The designated claims processor is:

For Medical & Vision Claims: For Prescription Drug Claims:CoreSource, Inc. CareMarkPost Office Box 8215 Box 659541Little Rock, AR 72221-8215 San Antonio, TX 78265-9541

For Dental Claims:Delta Dental of Arkansas (DDAR)c/o CoreSource, Inc.Post Office Box 15965North Little Rock, AR 72231

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SCHEDULE OF BENEFITSThe following Schedule of Benefits is designed as a quick reference. For complete provisions of the Plan's benefits, refer to the following sections: Medical/Dental/Vision Claim Filing Procedure, Medical Expense Benefit, Prescription Drug Program, Dental Expense Benefit, Vision Expense Benefit, Plan Exclusions and Preferred Provider or Nonpreferred Provider.

MEDICAL BENEFITS FOR ACTIVE

PARTICIPANTS AND MEDICARE SECONDARY

PARTICIPANTS:

Maximum Benefit Per Covered Person While Covered By This Plan For:

Medical Infertility/In-Vitro Fertilization

Unlimited$15,000

Maximum Benefit Per Covered Person Per Calendar Year For:Medical $1,250,000Chiropractic Care $1,000Skilled Nursing/Extended Care Facility 120 daysHome Health Care 40 visits

Deductible Per Calendar Year: (applies to preferred and nonpreferred providers)

Individual Deductible (Per Person) $2,000Family Deductible $4,000

If two or more covered members of a family are injured in the same accident and, as a result of that accident, incur covered expenses, only one individual deductible amount will be deducted from the total covered expenses of all covered family members related to the accident for the remainder of the calendar year.

Additional Per Confinement Deductible: (Refer to Medical Expense Benefit, Deductible)

Hospital Admission $500

Out-of-Pocket Expense Limit Per Calendar Year: (includes deductible) In-Network Out-of-Network

Individual (Per Person) $4,000 $8,000Family $8,000 $16,000

Refer to Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the out-of-pocket expense limit. Out-of-Pocket Expense Limits do not contribute toward each other.

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Coinsurance:The Plan pays the percentage listed on the following pages for covered expenses incurred by a covered person during a calendar year after the individual or family deductible has been satisfied and until the individual or family out-of-pocket expense limit has been reached. Thereafter, the Plan pays one hundred percent (100%) of covered expenses for the remainder of the calendar year or until the Essential Health Benefits/non-Essential Health Benefits maximum benefit has been reached. Refer to Medical Expense Benefit, Out-of-Pocket Expense Limit, for a listing of charges not applicable to the one hundred percent (100%) coinsurance. This 100% provision will not apply to expenses for any participant who has other medical coverage.

BENEFIT DESCRIPTION

Preferred Provider

(% of negotiated rate, if applicable,

otherwise % of customary and reasonable

amount)

Nonpreferred Provider

(% of customary and reasonable

amount)

Inpatient Hospital Additional Deductible Applies.

80% 70%

Preadmission Testing 100%* 100%*

Outpatient Surgery/Ambulatory Surgical Center 80%* 70%*

Emergency Room Services 80% 80%

Primary Care Physician (PCP) Office Visit(General Practitioner, Family Practice, OB/GYN, Internal Medicine and Pediatrician)

Physician's Services (other than PCP Office Visit)

$30 Copaythen 100%*

80%

70%

70%Diagnostic X-rays & LabInpatient or Outpatient

80% 70%

Second Surgical OpinionElective by Covered Person

100%* 100%*

Rehabilitation Facility 80% 70%

Extended Care Facility50% of the semi-private room rate from which the patient was transferred.Limitation: 120 days maximum benefit per calendar year

50% 50%

Home Health CareLimitation: 40 visits maximum benefit per calendar year

80% 70%

Hospice CareLimitation: 15 visits maximum benefit for family bereavement counseling

80% 70%

Smoking Cessation (for office visits to prescribe and monitor smoking cessation medications)

80% 70%

Durable Medical Equipment

Infertility/In-vitro Fertilization (Limited to $15,000 per lifetime)

80%

80%

70%

70%

* Deductible Waived

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BENEFIT DESCRIPTION

Preferred Provider



amount)



amount)

Children’s ImmunizationsLimitation: to age eighteen (18) maximum benefit

100%* 100%*

Wellness BenefitRoutine Physical Exams, Pap Smears, Immunizations, Mammograms, and Prostate Cancer Exams including office visits and any related laboratory charges. (Wellness Benefit charges over $1,200 will be subject to the regular benefit percentage and coinsurance) See Routine Preventive Care section.NOTE: Prostate Cancer Exams are not subject to any deductible.

100%* 100%*

Colorectal Cancer Examinations/Laboratory TestsSee Routine Preventive Care section.

80%* 70%*

Mental & Nervous Disorders Office Visit Services $30 Copay

then 100%*70%

Inpatient Services 80% 70%

Outpatient Services 80% 70%

Chemical DependencyOffice Visit Services $30 Copay

then 100%*70%

Inpatient Services 80% 70%Outpatient Services 80% 70%Therapy Services (Physical, Speech, Occupational, etc.) 80% 70%

Birthing Facility 80% 70%

Ambulance Services 80% 70%

Chiropractic CareLimitation: $1,000 maximum benefit per calendar year

80% 70%

Hearing Aids (please refer to Medical Expense Benefit, Hearing Aids)Limitation: Per Ear per 3-year period(this benefit is not subject to copays or deductibles)

80%* 70%*

CVS Caremark Specialty Pharmacy Program See Medical Expense Benefit, CVS Caremark Specialty Pharmacy Program section.

All Other Covered Expenses 80% 70%

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* Deductible Waived

ROUTINE VISION BENEFITS FOR ALL

COVERED PARTICIPANTS:

Deductible Per Covered Person Per Calendar Year: None

Percentage Payable: 100%

Examination Maximum Benefit (18 years of age and older):Limitation: One (1) exam per person per calendar year

$40

Examination Maximum Benefit (up to 18 years of age):Limitation: One (1) exam per person per calendar year

Note: Dollar maximums do not apply to dependent children under the age of eighteen (18)Corrective Lenses/Frames OR Contact Lenses Maximum Benefit: $200Limitation: Per covered person per calendar year

Note: Dollar maximums do not apply to dependent children under the age of eighteen (18)

Refer to Vision Expense Benefit for complete details.

DENTAL BENEFITS FOR ALL

COVERED PARTICIPANTS:

Deductible Per Calendar Year:

Individual $100

The deductible is waived for diagnostic & preventive dental services.

Maximum Benefit Per Covered Person For:

Diagnostic, Preventive & Basic dental services per calendar year for covered persons eighteen (18) years of age and older)

Diagnostic, Preventive & Basic dental services per calendar year for covered persons under age eighteen (18) (other than Orthodontics)

$500

$1,250,000

Percentage Payable of Maximum Plan Allowance For:

Class I - Diagnostic & Preventive Dental Services 100%

Class II - Basic Dental Services 80%

Refer to Dental Expense Benefit for complete details.

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PRESCRIPTION DRUG PROGRAM FOR ALL COVERED PARTICIPANTS:

Retail Deductible Per Calendar Year Per Person: $100

Retail Pharmacy OptionPrescription Drug Card 100% after copayCopay Generic: $10 copay

Preferred Brand Name: $40 copayNonpreferred Brand Name: $60 copay

Limitation: 30 day supply

Mail Order Option Deductible does not apply to Mail Order.Mail Order Prescription 100% after copayCopay Generic: $20 copay

Preferred Brand Name: $80 copayNonpreferred Brand Name: $120 copay

Limitation: 90 day supply

Refer to Prescription Drug Program for complete details.

SPECIAL NOTICE: The covered person and the prescribing physician must both agree to change to a drug or medication not included in the drug formulary when the equivalent has been ineffective in treatment or has caused or is expected to cause adverse or harmful reactions to the covered person, as determined by the prescribing physician. The specific drug or medication will be subject to the same benefits as formulary medications, provided the covered person utilizes an In-Network Pharmacy.

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MEDICAL BENEFITS FOR RETIRED PARTICIPANTS:

MEDICAL SCHEDULE OF BENEFITSFOR RETIRED PARTICIPANTS

When Retired Employees or their Dependents become eligible under Medicare, all of the following will happen:

Medicare pays benefits first. All health benefits then in effect for that person stop and are replaced with a new benefit to complement

Medicare. The new benefit is a Major Medical Benefit. Eligible Charges incurred prior to a person becoming eligible under Medicare in the Calendar Year in which the

person becomes eligible under Medicare may be used to satisfy the Cash Deductible under the new Major Medical Benefit for that Calendar Year.

Payment for any day of confinement or any treatment, services, or supplies given after the date the person becomes eligible under Medicare is made only under the new Major Medical Benefit.

This new Major Medical Benefit is only for persons eligible under Medicare. It does not apply to any participant unless that participant becomes eligible under Medicare.

The Major Medical Benefit for Retired Employees pays Eligible Charges that are more than the amounts payable for the same expenses under both of the following:

Medicare Parts A and B. Any plan of basic medical benefits sponsored by the Employer for persons eligible under Medicare.

Each participant must satisfy a Cash Deductible of $250 each Calendar Year before any payment is made. The Cash Deductible is the amount of Eligible Charges you must first pay each year for each participant.

If a participant:

Incurs Eligible Charges during October, November, or December; and Uses these Eligible Charges to satisfy the Cash Deductible,

They will also be counted toward that participant’s Cash Deductible for the following year.

If two (2) or more family members are hurt in the same accident, only one (1) Cash Deductible will have to be paid for all expenses incurred by the family due to that accident each year.

Then the benefit pays the following percentage of Eligible Charges:

80% of the UCR amount for PPO Providers and 70% of the UCR amount for Non-PPO Providers.

The Eligible Charges payable under this Major Medical Benefit for Retired Employees are the same Eligible Charges payable under Medicare with the exception of Prescription Drug charges.

If the provider has agreed to limit charges for services and supplies to the charges allowed by Medicare (participation physicians), this Plan determines the amount of Eligible Charges based on the amount of charges allowed by Medicare.

If the provider has not agreed to limit charges for services and supplies to the charges allowed by Medicare (non-participating physician), this Plan determines the amount of Eligible Charges based on the lesser of the following:

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The Reasonable Charges. The amount of the Limiting Charges as defined by Medicare.

OUT-OF-POCKET FEATURE

The Out-of-Pocket Feature does not apply to charges incurred because of cost containment penalties, nor charges incurred due to reduction of UCR nor prescription drug card copays nor Inpatient Hospital Confinement Deductibles. The aforementioned charges will never be paid at 100%, even after the Out-of-Pocket Maximum has been reached.

The amount of Eligible Charges, including the Cash Deductible that you pay, are counted toward the In-Network Out-of-Pocket Maximum or the Out-of-Network Out-of-Pocket Maximum, as applicable. The In-Network Out-of-Pocket Maximum is $2,500 and the Out-of-Network Out-of-Pocket Maximum is $2,500; please note these are separate and do not contribute toward each other. When the Out-of-Pocket Maximum for In-Network is reached for any one person in a Calendar Year, In-Network Eligible Charges, other than those shown above, are payable at 100% for that same person for the rest of that year. When the Out-of-Pocket Maximum for Out-of-Network is reached for any one person in a Calendar Year, Out-of-Network Eligible Charges, other than those shown above, are payable at 100% for that same person for the rest of that year.

MAXIMUM BENEFIT

The Maximum Benefit payable per Calendar Year for each participant is $1,250,000.

The maximum will include any amount paid under the Employer’s Comprehensive Medical Benefit for persons eligible under Medicare in effect prior to the Effective Date.

EXCLUSIONS

The exclusions shown in the “Exclusions” section of this Plan Document also apply to this Major Medical Benefit for Retired Employees and includes ineligible charges under Medicare with the exception of Prescription Drug charges.

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SCHEDULE OF BENEFITS FOR MEDICARE PRIMARY

PARTICIPANTS:

Maximum Benefit Per Covered Person While Covered By This Plan For:

Medical Unlimited Infertility/In-vitro Fertilization $15,000

Maximum Benefit Per Covered Person Per Calendar Year For:Medical $1,250,000Chiropractic Care $1,000Skilled Nursing/Extended Care Facility 120 daysHome Health Care 40 visits

Deductible Per Calendar Year: (applies to preferred and nonpreferred providers)

Individual Deductible (Per Person) $250Family Deductible $500


Additional Per Confinement Deductible: (Refer to Medical Expense Benefit, Deductible)

Hospital Admission $200

Out-of-Pocket Expense Limit Per Calendar Year: (includes deductible) In-Network Out-of-Network

Individual (Per Person) $2,500 $2,500Family $5,000 $5,000

Refer to Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the out-of-pocket expense limit. Out-of-Pocket Expense Limits do not contribute toward each other.

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Coinsurance:

The Plan pays the percentage listed on the following pages for covered expenses incurred by a covered person during a calendar year after the individual or family deductible has been satisfied and until the individual or family out-of-pocket expense limit has been reached. Thereafter, the Plan pays one hundred percent (100%) of covered expenses for the remainder of the calendar year or until the Essential Health Benefits/non-Essential Health Benefits maximum benefit has been reached. Refer to Medical Expense Benefit, Out-of-Pocket Expense Limit, for a listing of charges not applicable to the one hundred percent (100%) coinsurance. This 100% provision will not apply to expenses for any participant who has other medical coverage.

BENEFIT DESCRIPTION

Preferred Provider



amount)



amount)

Inpatient Hospital Additional Deductible Applies.

80% 70%

Preadmission Testing 100%* 100%*

Outpatient Surgery/Ambulatory Surgical Center 80%* 70%*

Emergency Room Services 80% 80%

Physician's Services 80% 70%

Diagnostic X-rays & LabInpatient or Outpatient

80% 70%

Second Surgical OpinionElective by Covered Person

100%* 100%*

Rehabilitation Facility 80% 70%

Extended Care Facility50% of the semi-private room rate from which the patient was transferred.Limitation: 120 days maximum benefit per calendar year

50% 50%

Home Health CareLimitation: 40 visits maximum benefit per calendar year

80% 70%

Hospice CareLimitation: 15 visits maximum benefit for family bereavement counseling

80% 70%

Smoking Cessation (for office visits to prescribe and monitor smoking cessation medications)

80% 70%


Infertility/In-vitro Fertilization (Limited to $15,000 per lifetime)

80%

80%

70%

70%

* Deductible Waived

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BENEFIT DESCRIPTION

Preferred Provider



amount)



amount)

Children’s ImmunizationsLimitation: to age eighteen (18) maximum benefit

100%* 100%*

Wellness BenefitRoutine Physical Exams, Pap Smears, Immunizations, Mammograms, and Prostate Cancer Exams including office visits and any related laboratory charges. (Wellness Benefit charges over $1,200 will be subject to the regular benefit percentage and coinsurance.) See Routine Preventive Care section.NOTE: Prostate Cancer Exams are not subject to any deductible.

100%* 100%*

Colorectal Cancer Examinations/Laboratory TestsSee Routine Preventive Care section.

80%* 70%*

Mental & Nervous Disorders

Office Visit Services 80% 70%



Chemical DependencyOffice Visit Services 80% 70%



Therapy Services (Physical, Speech, Occupational, etc.) 80% 70%

Birthing Facility 80% 70%

Ambulance Services 80% 70%

Chiropractic CareLimitation: $1,000 maximum benefit per calendar year

80% 70%

Hearing Aids (please refer to Medical Expense Benefit, Hearing Aids)Limitation: Per Ear per 3-year period(this benefit is not subject to copays or deductibles)

80%* 70%*

All Other Covered Expenses 80% 70%

CVS Caremark Specialty Pharmacy Program See Medical Expense Benefit, CVS Caremark Specialty Pharmacy Program section.

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* Deductible Waived

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PREFERRED PROVIDER OR NONPREFERRED PROVIDER

Covered persons have the choice of using either a preferred provider or a nonpreferred provider.

PREFERRED PROVIDERS

A preferred provider is a physician, hospital or ancillary service provider which has an agreement in effect with the Preferred Provider Organization (PPO) to accept a reduced rate for services rendered to covered persons. This is known as the negotiated rate. The preferred provider cannot bill the covered person for any amount in excess of the negotiated rate. Covered persons should contact the employer's Human Resources Department for a current listing of preferred providers.

NONPREFERRED PROVIDERS

A nonpreferred provider does not have an agreement in effect with the Preferred Provider Organization. This Plan will allow only the customary and reasonable amount as a covered expense. The Plan will pay its percentage of the customary and reasonable amount for the nonpreferred provider services, supplies and treatment. The covered person is responsible for the remaining balance. This results in greater out-of-pocket expenses to the covered person.

EXCEPTIONS

The following listing of exceptions represents services, supplies or treatments rendered by a nonpreferred provider where covered expenses shall be payable at the preferred provider level of benefits:

1. Emergency treatment rendered at a nonpreferred provider facility or at a preferred provider facility by a nonpreferred provider. If the covered person is admitted to the hospital on an emergency basis, covered expenses shall be payable at the preferred provider level.

2. Nonpreferred anesthesiologist and/or assistant surgeon if the operating surgeon is a preferred provider and when the facility rendering such services is a preferred provider.

3. Radiologist or pathologist services for interpretation of x-rays and diagnostic laboratory and surgical pathology tests rendered by a nonpreferred provider when the facility rendering such services is a preferred provider.

4. Diagnostic laboratory and surgical pathology tests referred to a nonpreferred provider by a preferred provider.

5. While the covered person is confined to a preferred provider hospital, the preferred provider physician requests a consultation from a nonpreferred provider or a newborn visit as performed by a nonpreferred provider.

6. Medically necessary services, supplies and treatments not available through any preferred provider.

7. When a covered dependent resides outside the service area of the Preferred Provider Organization, for example a full-time student, covered expenses shall be payable at the preferred provider level of benefits.

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8. Covered persons who do not have access to preferred providers within thirty (30) miles of their place of residence, or for emergency treatment rendered while traveling out-of-area.

9. Treatment rendered at a facility of the uniformed services or Indian Health Care facility.

10. Treatment provided by a preferred provider who terminates participation in the Preferred Provider Organization, until the earlier of; the current treatment of an acute condition is completed or ninety (90) days following the provider’s termination date, whichever comes first.

11. Treatment provided by a nonpreferred provider to a newly covered person under the Plan, until the earlier of; current treatment of an acute condition is completed or ninety (90) days following the covered person’s effective date, whichever comes first.

EXCEPTIONS ONLY APPLICABLE TO CVS CAREMARK SPECIALTY PHARMACY PROGRAM

1. Covered person who is identified, as under hospice care is not required to participate in this program.

2. Covered person is unable to administer the specialty drug or locate a contracted service.

3. In cases where the covered person has an immediate need for a specialty medication through a retail provider.

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MEDICAL EXPENSE BENEFITThis section describes the covered expenses of the Plan. All covered expenses are subject to applicable Plan provisions including, but not limited to: deductible, copay, coinsurance and maximum benefit provisions as shown on the Schedule of Benefits, unless otherwise indicated. Any portion of an expense incurred by the covered person for services, supplies or treatment, that is greater than the customary and reasonable amount for nonpreferred providers or negotiated rate for preferred providers will not be considered a covered expense by this Plan.

COPAY

The copay is the amount payable by the covered person for certain services, supplies or treatment rendered by a preferred provider. The service and applicable copay are shown on the Schedule of Benefits. The covered person selects a preferred provider and pays the preferred provider the copay. The Plan pays the remaining covered expenses at the negotiated rate. The copay must be paid each time a treatment or service is rendered. The copay will not be applied toward the following:

1. The calendar year deductible.

2. The maximum out-of-pocket expense.

3. The deductible carry-over.

4. The common accident deductible.

5. Multiple birth deductible.

6. Hospital deductible.

DEDUCTIBLES

Hospital Deductible

For each inpatient hospital confinement, the covered person is responsible for an additional hospital deductible as specified on the Schedule of Benefits. The hospital deductible shall be applied to covered expenses first, then any applicable calendar year deductible shall be applied.

Individual Deductible

The individual deductible is the dollar amount of covered expense that each covered person must have incurred during each calendar year before the Plan pays applicable benefits. The individual deductible amount is shown on the Schedule of Benefits.

Family Deductible

If, in any calendar year, covered members of a family incur covered expenses that are subject to the deductible that are equal to or greater than the dollar amount of the family deductible shown on the Schedule of Benefits, then the family deductible will be considered satisfied for all family members for that calendar year. Any number of family members may help to meet the family deductible amount, but no more than each person's individual deductible amount may be applied toward satisfaction of the family deductible by any family member.

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Common Accident


Deductible Carry-Over

Amounts incurred during October, November and December and applied toward the individual deductible of any covered person, will also be applied to the individual deductible of that covered person in the next calendar year.

Multiple Birth Deductible

When two (2) or more dependents are born in a multiple birth, only one individual deductible will be taken from the total covered expenses incurred in a calendar year for those dependents if the covered expenses are incurred in the same calendar year as the birth and are due to:

1. Premature birth; or

2. Abnormal congenital conditions; or

3. Injury which is incurred or illness which starts not more than thirty (30) days after birth.

COINSURANCE

The Plan pays a specified percentage of covered expenses at the customary and reasonable amount for nonpreferred providers, or the percentage of the negotiated rate for preferred providers. That percentage is specified on the Schedule of Benefits. For nonpreferred providers, the covered person is responsible for the difference between the percentage the Plan paid and 100% of the billed amount. The covered person's portion of the coinsurance represents the out-of-pocket expense limit.

OUT-OF-POCKET EXPENSE LIMIT

After the covered person has incurred an amount equal to the out-of-pocket expense limit listed on the Schedule of Benefits for covered expenses, the Plan will begin to pay 100% for covered expenses for the remainder of the calendar year.

After a covered family has incurred a combined amount equal to the family out-of-pocket expense limit shown on the Schedule of Benefits, the Plan will pay 100% of covered expenses for all covered family members for the remainder of the calendar year.

This 100% provision will not apply to expenses for any participant who has other group medical coverage.

Out-of-Pocket Expense Limit Exclusions

The following items do not apply toward satisfaction of the calendar year out-of-pocket expense limit:

1. Expenses for services, supplies and treatments not covered by this Plan, to include charges in excess of the customary and reasonable amount.

2. Copays.

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3. Expenses incurred as a result of failure to obtain precertification.

4. In-Network Out-of-Pocket Expense Limits DO NOT contribute toward Out-of-Network Out-of-Pocket Expense Limits and vice versa.

MAXIMUM BENEFIT

The Schedule of Benefits contains a separate annual maximum benefit. The Schedule of Benefits may also contain separate maximum benefit limitations for specified conditions and/or services. Any separate maximum benefit will include all such benefits paid by the Plan for the covered person during any and all periods of coverage under this Plan. No more than the maximum benefit will be paid for any covered person while covered by this Plan.

Notwithstanding any provision of the Plan to the contrary, all benefits received by an individual under any benefit option, package or coverage under the Plan shall be applied toward the Essential Health Benefits/non-Essential Health Benefits maximum benefit paid by the Plan for any one covered person for such option, package or coverage under the Plan, and also toward the Essential Health Benefits/non-Essential Health Benefits maximum benefit under any other options, packages or coverages under the Plan in which the individual may participate in the future.

The maximum benefit for Essential Health Benefits and non-Essential Health Benefits is tracked separately.

HOSPITAL/AMBULATORY SURGICAL FACILITY

Inpatient hospital admissions are subject to precertification. Failure to obtain precertification will result in a reduction of benefits (refer to Medical Claim Filing Procedure).

Covered expenses shall include:

1. Room and board for treatment in a hospital, including intensive care units, cardiac care units and similar medically necessary accommodations. Covered expenses for room and board shall be limited to the hospital's semiprivate rate except room and board in an all-private room facility will be allowed at 90% of the customary and reasonable amount. Covered expenses for intensive care or cardiac care units shall be the customary and reasonable amount for nonpreferred providers and the percentage of the negotiated rate for preferred providers. (NOTE: A full private room rate is covered if the private room is necessary for isolation purposes and is not for the convenience of the covered person.)

2. Miscellaneous hospital services, supplies, and treatments including, but not limited to:

a. Admission fees, and other fees assessed by the hospital for rendering services, supplies and treatments;

b. Use of operating, treatment or delivery rooms;c. Anesthesia, anesthesia supplies and its administration by an employee of the hospital;d. Medical and surgical dressings and supplies, casts and splints;e. Blood transfusions, including the cost of whole blood, the administration of blood, blood

processing and blood derivatives (to the extent blood or blood derivatives are not donated or otherwise replaced);

f. Drugs and medicines (except drugs not used or consumed in the hospital);g. X-ray and diagnostic laboratory procedures and services;h. Oxygen and other gas therapy and the administration thereof;i. Therapy services.

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3. Services, supplies and treatments described above furnished by an ambulatory surgical facility, including follow-up care provided within seventy-two (72) hours of a procedure.

4. Charges for preadmission testing (x-rays and lab tests) performed within seven (7) days prior to a hospital admission which are related to the condition which is necessitating the confinement. Such tests shall be payable even if they result in additional medical treatment prior to confinement or if they show that hospital confinement is not medically necessary. Such tests shall not be payable if the same tests are performed again after the covered person has been admitted.

EMERGENCY SERVICES/EMERGENCY ROOM SERVICES

Covered expenses for emergency services in the emergency department of a hospital shall be paid in accordance with the Schedule of Benefits.

FACILITY PROVIDERS

Services of facility providers if such services would have been covered if performed in a hospital or ambulatory surgical facility.

AMBULANCE SERVICES

Ambulance services must be by a regularly scheduled airline or by a licensed air or ground ambulance.


1. Ambulance services for air or ground transportation for the covered person from the place of injury or serious medical incident to the nearest hospital where treatment can be given.

2. Ambulance service is covered in a non-emergency situation only to transport the covered person to or from a hospital or between hospitals for required treatment when such transportation is certified by the attending physician as medically necessary. Such transportation is covered only from the initial hospital to the nearest hospital qualified to render the special treatment.

3. Emergency services actually provided by an advance life support unit, even though the unit does not provide transportation.

If the covered person is admitted to a nonpreferred hospital after emergency treatment, ambulance service is covered to transport the covered person from the nonpreferred hospital to a preferred hospital after the patient’s condition has been stabilized, provided such transport is certified by the attending physician as medically necessary.

PHYSICIAN SERVICES


1. Medical treatment, services and supplies including, but not limited to: office visits, inpatient visits, home visits.

2. Surgical treatment. Separate payment will not be made for inpatient pre-operative or post-operative care normally provided by a surgeon as part of the surgical procedure.

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3. For related operations or procedures performed through the same incision or in the same operative field, covered expenses shall include the surgical allowance for the highest paying procedure, plus fifty (50) percent of the surgical allowance for second highest paying procedure and twenty-five (25) percent of the surgical allowance for each additional procedure.

4. Surgical assistance provided by a physician if it is determined that the condition of the covered person or the type of surgical procedure requires such assistance.

5. Furnishing or administering anesthetics, other than local infiltration anesthesia, by other than the surgeon or his assistant.

6. Consultations requested by the attending physician during a hospital confinement. The Plan will pay for one such consultation per illness or injury. Consultations do not include staff consultations which are required by a hospital's rules and regulations.

7. Radiologist or pathologist services for interpretation of x-rays and laboratory tests necessary for diagnosis and treatment.

8. Radiologist or pathologist services for diagnosis or treatment, including radiation therapy and chemotherapy.

9. Allergy testing consisting of percutaneous, intracutaneous and patch tests.

SECOND SURGICAL OPINION

The second surgical opinion benefit is not subject to any deductible.

1. Benefits for a second surgical opinion will be payable according to the Schedule of Benefits if an elective surgical procedure (non-emergency surgery) is recommended by the physician.

2. The physician rendering the second opinion regarding the medical necessity of such surgery must be a board certified specialist in the treatment of the covered person's illness or injury and must not be affiliated in any way with the physician who will be performing the actual surgery.

3. In the event of conflicting opinions, a request for a third opinion may be obtained. The Plan will consider payment for a third opinion the same as a second surgical opinion.

4. The second surgical opinion benefit includes physician services and any diagnostic services as may be required.

DIAGNOSTIC SERVICES AND SUPPLIES

Covered expenses shall include services and supplies for diagnostic laboratory, pathology, ultrasound, nuclear medicine, magnetic imaging and x-ray.

TRANSPLANT

Transplant procedures are subject to precertification. Failure to obtain precertification will result in a reduction of benefits to your hospital confinement as outlined in the Medical Claim Filing Procedure section of this document.

Services, supplies and treatments in connection with human-to-human organ and tissue transplant procedures will be considered covered expenses subject to the following conditions:

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1. When the recipient is covered under this Plan, the Plan will pay the recipient's covered expenses related to the transplant.

2. When the donor is covered under this Plan, the Plan will pay the donor's covered expenses related to the transplant.

3. Expenses incurred by the donor who is not ordinarily covered under this Plan according to Eligibility requirements will be covered expenses to the extent that such expenses are not payable by any other form of health coverage, including any government plan or individual policy of health coverage, and provided the recipient is covered under this Plan. The donor's expense shall be applied to the recipient's maximum benefit. In no event will benefits be payable in excess of the maximum benefit still available to the recipient.

4. Surgical, storage and transportation costs directly related to procurement of an organ or tissue used in a transplant procedure will be covered for each procedure completed. If an organ or tissue is sold rather than donated, the purchase price of such organ or tissue shall not be considered a covered expense under this Plan.

If a covered person's transplant procedure is not performed as scheduled due to the intended recipient's medical condition or death, benefits will be paid for organ or tissue procurement as described above.

Centers of Excellence Program

In addition to the above Transplant benefits, the covered person may be eligible to participate in a Centers of Excellence Program. Covered persons should contact the Health Care Management Organization to discuss this benefit by calling:

1-866-292-8108

A Center of Excellence is a facility within a Centers of Excellence Network that has been chosen for their proficiency in performing one or more transplant procedures. Usually located throughout the United States, the Centers of Excellence facilities have greater transplant volumes and surgical team experience than other similar facilities.

Through regular recredentialing, the Network sponsoring the Centers of Excellence Program determines whether each hospital within their Network maintains high quality standards to include transplant services and the transplant team composition. Transplant volumes and outcomes are regularly monitored by the Network Credentialing Com -mittee to assure continued compliance with strict established credentialing criteria.

Transplant procedures are subject to precertification. Failure to obtain precertification will result in a reduction of benefits to your hospital confinement as outlined in the Medical Claim Filing Procedure section of this document.

PREGNANCY

Covered expenses for pregnancy or complications of pregnancy shall be provided for a covered female employee, a covered female spouse of a covered employee, and dependent female children.

In the event of early discharge from a hospital or birthing center following delivery, the Plan will cover two (2) Registered Nurse home visits.

The Plan shall cover services, supplies and treatments for medically necessary abortions when the life of the mother would be endangered by continuation of the pregnancy, or when the fetus has a known condition incompatible with life, or when the pregnancy is a result of rape or incest.

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Complications from an abortion shall be a covered expense whether or not the abortion is a covered expense.

BIRTHING CENTER

Covered expenses shall include services, supplies and treatments rendered at a birthing center provided the physician in charge is acting within the scope of his license and the birthing center meets all legal requirements. Services of a midwife acting within the scope of his license or registration are a covered expense provided that the state in which such service is performed has legally recognized midwife delivery.

STERILIZATION

Covered expenses shall include elective sterilization procedures for the covered employee or covered spouse. Reversal of sterilization is not a covered expense.

INFERTILITY SERVICES

Covered expenses shall include expenses for infertility testing, and infertility treatment for employees and their covered spouse.

The following conditions must all be met:

1. The patient and patient’s spouse must have a history of infertility of at least two (2) years and;2. The patient’s oocytes must be fertilized with her spouse’s sperm and;3. The infertility must be associated with one or more of the following medical conditions:

a. Endometriosis;b. Exposure in utero to Diethylstilbestrol;c. Blockage of, or removal of, one or both fallopian tubes except if due to voluntary sterilization

and;d. Abnormal male factors contributing.

4. The patient must have been unable to attain a successful pregnancy through other applicable treatments for which coverage is provided and;

5. The in-vitro fertilization procedures must be performed at:a. A facility licensed or certified by the state as an in-vitro fertilization clinic; orb. A medical facility that conforms to the American College of Obstetric and Gynecology guidelines

for in-vitro fertilization clinics or the American Fertility Society minimal standards for programs of

in-vitro fertilization.

Cryopreservation shall be included as an in-vitro fertilization procedure. Any pre-existing limitation for infertility shall not exceed a period of twelve (12) months.

Treatment of infertility shall be subject to the maximum benefit as shown on the Schedule of Benefits.

WELL NEWBORN CARE

The Plan shall cover well newborn care for covered newborn dependents while the mother is confined for delivery.

Such care shall include, but is not limited to:

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1. Physician services

2. Hospital services

3. Circumcision

CHILDREN’S IMMUNIZATIONS

Charges for routine immunizations for children up to the age of eighteen (18) and payable according to the Schedule of Benefits

ROUTINE PREVENTIVE CARE/WELLNESS BENEFITS

Covered expenses for routine examinations include services such as a routine physical examination and related lab per year, one (1) pap smear per calendar year per covered participant, immunizations, one (1) mammogram per year, and one (1) prostate cancer screening which is subject to the following state regulations:

Prostate cancer screenings and related charges are not subject to any deductible; Prostate cancer screenings shall be performed by a qualified medical professional; One screening per year for covered men who are forty (40) years of age or older; Prostate cancer screening required under this section does not diminish or limit diagnostic benefits

otherwise allowable under the Plan and; Prostate cancer screenings may not be denied based on the covered person having a previous digital rectal

examination that was negative.

Includes office visits and any related laboratory charges.

Routine Preventive Care/Wellness Benefits are payable as specified on the Schedule of Benefits.

The Plan will apply reasonable medical management techniques to determine the appropriate frequency, method, treatment, or setting for a preventive item or service to the extent that such techniques are not specified in the recommendations or guidelines.

COLORECTAL CANCER EXAMINATIONS

Covered expenses shall include colorectal cancer examinations and appropriate laboratory tests for covered persons age fifty (50) and over; covered persons who are less than fifty (50) years of age who are at high risk for colorectal cancer according to the American Cancer Society colorectal cancer screening guidelines as they exist; and covered persons experiencing the following symptoms of colorectal cancer as determined by a physician licensed under the Arkansas Medical Practices Act, which are:

Bleeding from the rectum or blood in the stool; or A change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts more than five

(5) days.

The colorectal screening should involve an examination of the entire colon, including the following exams or laboratory tests, or both:

An annual fecal occult blood test utilizing the take-home multiple sample method, or an annual fecal immunochemical test in conjunction with a flexible sigmoidoscopy every five (5) years; or

A double-contrast barium enema every five (5) years; or

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A colonoscopy every five (5) years; AND Any additional medically recognized screening test for colorectal cancer required by the Director of Health,

determined in consultation with appropriate health care organizations.

Screening shall be limited to the following guidelines for the management or subsequent need for follow-up colonoscopy:

If the initial colonoscopy is normal, follow-up is recommended in ten (10) years; For covered persons with one or more neoplastic polyps or adenomatous polyps, assuming that the initial

colonoscopy was complete to the cecum and adequate preparation and removal of all visualized polyps, follow-up is recommended in three (3) years;

If single tubular adenoma of less than one (1) centimeter (1cm) is found, follow-up is recommended in five (5) years; and

For patients with large sessile adenomas greater than three (3) centimeters (3cm), especially if removed in piecemeal fashion, follow-up is recommended in six (6) months or until complete polyp removal is verified by colonoscopy.

THERAPY SERVICES

Therapy services must be ordered by a physician to aid restoration of normal function lost due to illness or injury, for congenital anomaly, or for prevention of continued deterioration of function. Covered expenses shall include:

1. Services of a professional provider for physical therapy, occupational therapy, speech therapy or respiratory therapy.

2. Radiation therapy and chemotherapy.

3. Dialysis therapy or treatment.

4. Infusion therapy.

EXTENDED CARE FACILITY

Extended care facility confinement is subject to precertification. Failure to obtain precertification shall result in a reduction of benefits to your hospital confinement as outlined in the Medical Claim Filing Procedure section.

Extended care facility services, supplies and treatments shall be a covered expense provided:

1. The covered person was first confined in a hospital for at least three (3) consecutive days;

2. The attending physician recommends extended care confinement for a convalescence from a condition which caused that hospital confinement, or a related condition;

3. The extended care confinement begins within fourteen (14) days after discharge from that hospital confinement; and

4. The covered person is under a physician's continuous care and the physician certifies that the covered person must have twenty-four (24) hours-per-day nursing care.


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1. Room and board (including regular daily services, supplies and treatments furnished by the extended care facility) limited to the facility's average semiprivate room rate; and

2. Other services, supplies and treatment ordered by a physician and furnished by the extended care facility for inpatient medical care.

Extended care facility benefits are limited as shown the Schedule of Benefits.

HOME HEALTH CARE

Home health care enables the covered person to receive treatment in his home for an illness or injury instead of being confined in a hospital or extended care facility. Covered expenses shall include:

1. Part-time or intermittent nursing care by a Registered Nurse, Licensed Practical Nurse or a Licensed Vocational Nurse;

2. Physical, respiratory, occupational or speech therapy;

3. Part-time or intermittent home health aide services for a covered person who is receiving covered nursing or therapy services;

4. Medical social service consultations;

5. Nutritional guidance by a registered dietitian and nutritional supplements such as diet substitutes administered intravenously or through hyperalimentation as determined to be medically necessary.

Covered expenses shall be subject to the maximum benefit specified on the Schedule of Benefits.

A visit by a member of a home health care team and four (4) hours of home health aide service will each be considered one (1) home health care visit.

No home health care benefits will be provided for dietitian services, homemaker services (except as may be specifically provided herein), maintenance therapy, dialysis treatment, food or home delivered meals, rental or purchase of durable medical equipment or prescription or non-prescription drugs or biologicals.

HOSPICE CARE

Hospice care is subject to precertification. Failure to obtain precertification shall result in a reduction of benefits to your hospital confinement as outlined in the Medical Claim Filing Procedure section.

Hospice care is a health care program providing a coordinated set of services rendered at home, in outpatient settings, or in facility settings for a covered person suffering from a condition that has a terminal prognosis.

Hospice benefits will be covered only if the covered person's attending physician certifies that:

1. The covered person is terminally ill, and

2. The covered person has a life expectancy of six (6) months or less.


1. Confinement in a hospice to include ancillary charges and room and board.

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2. Services, supplies and treatment provided by a hospice to a covered person in a home setting.

3. Physician services and/or nursing care by a Registered Nurse, Licensed Practical Nurse or a Licensed Vocational Nurse.

4. Physical therapy, occupational therapy, speech therapy or respiratory therapy.

5. Nutrition services to include nutritional advice by a registered dietitian, and nutritional supplements such as diet substitutes administered intravenously or through hyperalimentation as determined to be medically necessary.

6. Counseling services provided through the hospice.

7. Respite care by an aide who is employed by the hospice for up to four (4) hours per day. (Respite care provides care of the covered person to allow temporary relief to family members or friends from the duties of caring for the covered person).

8. Bereavement counseling is a supportive service to covered persons in the terminally ill covered person's immediate family. Benefits will be payable up to the maximum benefit shown on the Schedule of Benefits, provided:

a. On the date immediately before death, the terminally ill person was covered under the Plan and receiving hospice care benefits; and

b. Services are incurred by the covered person within six (6) months of the terminally ill person's death and shall be limited to a maximum of fifteen (15) visits.

Charges incurred during periods of remission are not eligible under this provision of the Plan. Any covered expense paid under hospice benefits will not be considered a covered expense under any other provision of this Plan.

DURABLE MEDICAL EQUIPMENT

Rental or purchase, whichever is less costly, of medically necessary durable medical equipment which is prescribed by a physician and required for therapeutic use by the covered person shall be a covered expense. Repair or replacement of purchased durable medical equipment that is medically necessary due to normal use or growth of a child will be considered a covered expense

Equipment containing features of an aesthetic nature or features of a medical nature which are not required by the covered person's condition, or where there exists a reasonably feasible and medically appropriate alternative piece of equipment which is less costly than the equipment furnished, will be covered based on the usual charge for the equipment which meets the covered person's medical needs.

PROSTHESES

The initial purchase of a prosthesis (other than dental) provided for functional reasons when replacing all or part of a missing body part (including contiguous tissue) or to replace all or part of the function of a permanently inoperative or malfunctioning body organ shall be a covered expense. Repair or replacement of a prosthesis that is medically necessary due to normal use or growth of a child will be considered a covered expense.

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Replacement penile implants or future reconstructive surgeries are not covered. Repairs to a penile implant shall be covered when made necessary due to an accident, provided repairs are initiated within ninety (90) days of the accident.

ORTHOTICS

Orthotic devices and appliances (a rigid or semi-rigid supportive device which restricts or eliminates motion for a weak or diseased body part), including initial purchase, fitting and repair shall be a covered expense. Orthopedic shoes or corrective shoes, unless they are an integral part of a leg brace, and other supportive devices for the feet shall not be covered, not to include medically necessary diabetic foot care. Replacement will be covered only after five (5) years from the date of original placement, unless growth and development of a child necessitates earlier replacement.

DENTAL SERVICES

Covered expenses shall include repair of sound natural teeth or surrounding tissue provided it is the result of an injury. Treatment must begin within twelve (12) months of the date of such injury. Damage to the teeth as a result of chewing or biting shall not be considered an injury under this benefit.

Covered expenses shall include charges for oral surgery such as the excision of partially or completely unerupted impacted teeth, excision of the entire tooth, closed or open reduction of fractures or dislocations of the jaw, and other incision or excision procedures performed on the gums and tissues of the mouth when not performed in conjunction with the extraction of teeth.

TEMPOROMANDIBULAR JOINT DYSFUNCTION

Surgical treatment of temporomandibular joint (TMJ), myofascial pain syndrome or orthognathic treatment shall be a covered expense, but shall not include orthodontia or prosthetic devices prescribed by a physician or dentist. This limitation shall apply whether surgical treatment is provided by a hospital, physician, dentist, physical therapist or oral surgeon.

If a physician or dentist recommends a course of surgical treatment for or in connection with TMJ, myofascial pain syndrome or orthognathic treatment, a covered person may submit the treatment plan, including x-rays and study models, for predetermination of benefits under the Plan.

The claims processor will determine if the surgical treatment is a covered expense and will notify the covered person in writing.

SPECIAL EQUIPMENT AND SUPPLIES

Covered expenses shall include medically necessary special equipment and supplies including, but not limited to: casts; splints; braces; trusses; surgical and orthopedic appliances; colostomy and ileostomy bags and supplies required for their use; catheters; syringes and needles for diabetes; other diabetic supplies, including insulin, test strips and blood sugar measurement devices; allergy serums; crutches; electronic pacemakers; gastric pacemakers; oxygen and the administration thereof; the initial pair of eyeglasses or contact lenses due to cataract surgery; soft lenses or sclera shells intended for use in the treatment of illness or injury of the eye; support stockings, such as Jobst stockings, shall be limited to two (2) pairs per calendar year; surgical dressings and other medical supplies ordered by a professional provider in connection with medical treatment, but not common first aid supplies.

HEARING AIDS

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This Plan shall offer coverage for a hearing aid or hearing instrument sold on or after January 1, 2011, by a professional licensed by the state of Arkansas, to dispense a hearing aid or hearing instrument. This benefit includes repair and replacement parts and can be worn in or on the body.

This Plan shall provide coverage per ear for each three-year period, beginning on the first day of coverage and is not subject to any copays, or deductibles.

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COSMETIC SURGERY

Cosmetic surgery or reconstructive surgery shall be a covered expense provided:

1. A covered person receives an injury as a result of an accident and as a result requires surgery. Cosmetic or reconstructive surgery and treatment must be for the purpose of restoring the covered person to his normal function immediately prior to the accident.

2. It is required to correct a congenital anomaly, for example, a birth defect, for a child.

MASTECTOMY (WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998)

This Plan intends to comply with the provisions of the federal law known as the Women's Health and Cancer Rights Act of 1998.

Covered expenses will include eligible charges related to medically necessary mastectomy.

For a covered person who elects breast reconstruction in connection with such mastectomy, covered expenses will include:

a. reconstruction of a surgically removed breast; and

b. surgery and reconstruction of the other breast to produce a symmetrical appearance.

c. An external breast prosthesis shall be covered once every three (3) calendar years, unless recommended more frequently by a physician. The first permanent internal breast prosthesis necessary because of a mastectomy shall also be a covered expense.

Prostheses (and medically necessary replacements) and physical complications from all stages of mastectomy, including lymphedemas will also be considered covered expenses following all medically necessary mastectomies.

MENTAL AND NERVOUS DISORDERS

Inpatient Confinement

Subject to the precertification provisions of the Plan, the Plan will pay the applicable coinsurance, as shown on the Schedule of Benefits, for confinement in a hospital or treatment center for treatment, services and supplies related to the treatment of mental and nervous disorders. The Plan will pay for treatment of mental and nervous disorders as any other illness, to include screening, diagnosis and treatment of autism spectrum disorders.


1. Inpatient hospital confinement;

2. Individual psychotherapy;

3. Group psychotherapy;

4. Psychological testing;

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5. Electro-Convulsive therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider;

Outpatient

The Plan will pay the applicable coinsurance, as shown on the Schedule of Benefits, for outpatient treatment, services and supplies related to the treatment of mental and nervous disorders. Prescription drugs for the treatment of mental and nervous disorders shall be included in this mental and nervous disorder care benefit.

CHEMICAL DEPENDENCY

The Plan will pay for covered treatment of chemical dependency the same as treatment of any illness. Benefits shall be payable for inpatient or outpatient treatment in a hospital or treatment center by a physician or professional provider.

PRESCRIPTION DRUGS

The Plan shall cover prescription drugs as specified on the Schedule of Benefits. Such drugs must be approved by the Food and Drug Administration and must be dispensed by a licensed pharmacist, physician or dentist. Antigen and allergy vaccine dispensed by a physician or certified laboratory shall be a covered expense. Covered prescription expense shall include contraceptive implants and Depo-provera birth control shots. Vitamins, which require a prescription by law, and are used to treat a specific illness shall be considered a covered expense.

CVS CAREMARK SPECIALTY PHARMACY PROGRAM

The CVS Caremark Specialty Pharmacy Program is available for some specialty drugs. Specialty drugs are often high cost pharmaceuticals used in the management of chronic and/or complex conditions. To receive these specialty drugs, CVS Caremark Specialty Pharmacy will contact the covered person and the covered person’s physician to arrange for the distribution of the specialty drug directly from the CVS Caremark Specialty Pharmacy. Refer to the Schedule of Benefits, Prescription Drug Program, CVS Caremark Specialty Pharmacy Program section for benefit information, regarding specialty drugs.

OFF-LABEL DRUG USAGE/PHASE III CLINICAL TRIALS

OFF-LABEL DRUG USE. Charges for the use of an FDA-approved Drug for a purpose other than that for which it is approved. but only when the Drug is not excluded by the Plan and the Plan Sponsor determines in its sole discretion that the Drug is appropriate and generally accepted for the condition being treated.

ONCOLOGY CLINICAL TRIALS. Charges for a Drug, device, supply, treatment, procedure or service that is part of a scientific study of cancer therapy in a phase III clinical trial sponsored by the National Cancer Institute or institution of similar stature. Trials must have Institutional Review Board (IRB) approval by a qualified IRB. Charges that are not covered include:

a. Costs for services that are not primarily for the care of the patient (such as lab services performed solely to collect data for the trial).

b. Costs for services provided in a clinical trial that are funded by another source.

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PODIATRY SERVICES

Covered expenses shall include surgical podiatry services, including incision and drainage of infected tissues of the foot, removal of lesions of the foot, removal or débridement of infected toenails, surgical removal of nail root, and treatment of fractures or dislocations of bones of the foot.

PRIVATE DUTY NURSING

Medically necessary services of a private duty nurse shall be a covered expense.

CHIROPRACTIC CARE

Covered expenses include initial consultation, x-rays and treatment (but not maintenance care), subject to the maximum benefit shown on the Schedule of Benefits.

PATIENT EDUCATION

Covered expenses shall include medically necessary patient education programs including, but not limited to diabetic education and ostomy care.

SURCHARGES

Any excise tax, sales tax, surcharge, (by whatever name called) imposed by state or federal law, a governmental entity for services, supplies and/or treatments rendered by a professional provider; physician; hospital; facility or any other health care provider shall be a covered expense under the terms of the Plan.

ROUTINE VISION

Covered expenses shall include charges for routine vision examinations, glasses and contact lenses, as specified in the Vision Expense Benefit.

MEDICAL EXCLUSIONS

In addition to Plan Exclusions, no benefit will be provided under this Plan for medical expenses for the following:

1. Charges for pre-existing conditions as specified in Pre-existing Conditions and Certificates of Coverage.

2. Charges for services, supplies or treatment for the reversal of sterilization procedures.

3. Charges for services, supplies or treatment related to the diagnosis or treatment of infertility and artificial reproductive procedures, including, but not limited to: artificial insemination, surrogate mother, embryo implantation, or gamete intrafallopian transfer (GIFT), except as otherwise specified.

4. Charges for services, supplies or treatment for transsexualism, gender dysphoria or sexual reassignment or change, including medications, implants, hormone therapy, surgery, medical or psychiatric treatment.

5. Charges for treatment or surgery for sexual dysfunction, except due to loss of prostate, tissue or organ, to include penile implants. Replacement penile implants or future reconstructive surgeries are not covered. Repairs to a penile implant shall be covered when made necessary due to an accident, provided repairs are initiated within ninety (90) days of the accident.

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6. Charges for hospital admission on Friday, Saturday or Sunday unless the admission is an emergency situation, or surgery is scheduled within twenty-four (24) hours. If neither situation applies, hospital expenses will be payable commencing on the date of actual surgery.

7. Charges for inpatient room and board in connection with a hospital confinement primarily for diagnostic tests, unless it is determined by the Plan that inpatient care is medically necessary.

8. Charges for biofeedback therapy.

9. Charges for services, supplies or treatments which are primarily educational in nature; except as specified in Medical Expense Benefit, Patient Education; charges for services for educational or vocational testing or training and work hardening programs regardless of diagnosis or symptoms; charges for self-help training or other forms of non-medical self-care.

10. Charges for marital counseling.

11. Except as specifically stated in Medical Expense Benefit, Dental Services, charges for or in connection with: treatment of injury or disease of the teeth; oral surgery; treatment of gums or structures directly supporting or attached to the teeth; removal or replacement of teeth; or dental implants.

12. Charges for routine vision examinations and eye refractions; orthoptics; eyeglasses or contact lenses and dispensing optician’s services, except as specifically stated in the Vision Expense Benefit.

13. Charges for any eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia) and astigmatism including radial keratotomy by whatever name called; contact lenses and eyeglasses required as a result of such surgery.

14. Except as medically necessary for the treatment of metabolic or peripheral-vascular illness, charges for routine, palliative or cosmetic foot care, including, but not limited to: treatment of weak, unstable, flat, strained or unbalanced feet; subluxations of the foot; treatment of corns or calluses; non-surgical care of toenails.

15. Charges for services, supplies or treatment which constitute personal comfort or beautification items, whether or not recommended by a physician, such as: television, telephone, air conditioners, air purifiers, humidifiers, electric heating units, orthopedic mattresses, blood pressure instruments, scales, elastic bandages, non-hospital adjustable beds, exercise equipment.

16. Charges for nonprescription drugs, such as vitamins, cosmetic dietary aids, and nutritional supplements, except as provided in Medical Expense Benefit, Prescription Drugs.

17. Charges for orthopedic shoes (except when they are an integral part of a leg brace and the cost is included in the orthotist's charge or prescribed for diabetic foot care) or shoe inserts, or the purchase of orthotic services or appliances.

18. Expenses for a cosmetic surgery or procedure and all related services, except as specifically stated in Medical Expense Benefit, Cosmetic Surgery.

19. Charges incurred as a result of, or in connection with, any procedure or treatment excluded by this Plan which has resulted in medical complications.

20. Charges related to newborns of dependent children.

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21. Charges for services provided to a covered person for an elective abortion (See Pregnancy for specifics regarding the coverage of abortions), except for complications from a non-covered abortion as specified herein.

22. Charges for services, supplies or treatment primarily for weight reduction or treatment of obesity, including, but not limited to: exercise programs or use of exercise equipment; special diets or diet supplements; appetite suppressants; Nutri/System, Weight Watchers or similar programs; and hospital confinements for weight reduction programs, except as specifically provided herein.

23. Charges for surgical weight reduction procedures and all related charges, even if resulting from morbid obesity.

24. Any prescription refilled in excess of the number specified by the physician or any refill dispensed after one year from the physician's original order.

25. Charges for examination to determine hearing loss or the fitting, purchase, repair or replacement of a hearing aid, unless otherwise specified in the Schedule of Benefits.

26. Charges related to acupuncture treatment.

27. Charges for non-surgical treatment of temporomandibular joint syndrome and myofascial pain syndrome including, but not limited to: charges for treatment to alter vertical dimension or to restore abraded dentition, orthodontia and intra-oral prosthetic devices.

28. Charges for methods of treatment to alter vertical dimension.

29. Charges for custodial care, domiciliary care or rest cures.

30. Charges for travel or accommodations, whether or not recommended by a physician, except as specifically provided herein.

31. Charges for wigs, artificial hair pieces, artificial hair transplants, or any drug - prescription or otherwise -used to eliminate baldness or stimulate hair growth. This exclusion does not apply when baldness is the result of burns, chemotherapy, radiation therapy, or surgery.

32. Charges for expenses related to hypnosis.

33. Charges for professional services billed by a physician or Registered Nurse, Licensed Practical Nurse or Licensed Vocational Nurse who is an employee of a hospital or any other facility and who is paid by the hospital or other facility for the service provided.

34. Charges for environmental change including hospital or physician charges connected with prescribing an environmental change.

35. Charges for room and board in a facility for days on which the covered person is permitted to leave (a weekend pass, for example).

36. Charges for any services, supplies or treatment not specifically provided herein.

37. Charges for Drugs, devices, supplies, treatments, procedures or services that are considered experimental or investigational by the Plan. The Plan will consider a Drug, device, supply, treatment, procedure or service to be “experimental” or “investigational”:

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a. if, in the case of a device or supply, the device or supply cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the device or supply is furnished; or

b. if the Drug, device, supply, treatment, procedure or service, or the patient’s informed consent document utilized with respect to the Drug, device, supply, treatment, procedure or service was reviewed and approved by the treating facility’s institutional review board or other body serving a similar function, or if federal law requires such review or approval; or

c. if the Plan Sponsor determines in its sole discretion that the Drug, device, supply, treatment, procedure or service is the subject of on-going phase I or phase II clinical trials; is the research, experimental, study or investigational arm of on-going phase III clinical trials, or is otherwise under study to determine maximum tolerated dose, toxicity, safety or efficacy, however, a Drug, device, supply, treatment, procedure or service that meets the standards set in “Oncology Clinical Trials” or “Off-Label Drug” Use under Covered Expenses will not be deemed experimental or investigational solely by reason of this subparagraph; or

d. if the Plan Sponsor determines in its sole discretion based on documentation in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature that the prevailing opinion among experts regarding the Drug, device, supply, treatment, procedure or service is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety or efficacy.

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PRESCRIPTION DRUG PROGRAM

RETAIL PRESCRIPTION DRUG DEDUCTIBLE

Individual Deductible For Retail Prescriptions

The individual prescription drug deductible for Retail Prescriptions is the dollar amount of covered expense that each covered person must have incurred for the purchase of Retail prescription drugs during each calendar year before the Plan pays applicable benefits. The individual prescription drug deductible amount for Retail Prescriptions is shown on the Schedule of Benefits. (Mail Order Prescriptions are not subject to a deductible.)

PHARMACY OPTION

Participating pharmacies have contracted with the Plan to charge covered persons reduced fees for covered prescription drugs.

SPECIAL NOTICE: The covered person and the prescribing physician must both agree to change to a drug or medication not included in the drug formulary when the equivalent has been ineffective in treatment or has caused or is expected to cause adverse or harmful reactions to the covered person, as determined by the prescribing physician. The specific drug or medication will be subject to the same benefits as formulary medications, provided the covered person utilizes an In-Network Pharmacy.

PHARMACY OPTION COPAY

The copay is applied to each covered pharmacy drug charge and is shown on the Schedule of Benefits. The copay amount is not a covered expense under the Medical Expense Benefit. Any one prescription is limited to a thirty (30) day supply.

If a drug is purchased from a nonparticipating pharmacy or a participating pharmacy when the covered person’s ID card is not used, the covered person must pay the entire cost of the prescription, including copay, and then submit the receipt to the prescription drug card vendor for reimbursement. If a nonparticipating pharmacy is used, the covered person will be responsible for the copay, plus the difference in cost between the participating pharmacy and nonparticipating pharmacy.

MAIL ORDER OPTION

The mail order drug benefit option is available for maintenance medications (those that are taken for long periods of time, such as drugs which may be prescribed for heart disease, high blood pressure, asthma, etc.).

MAIL ORDER OPTION COPAY

The copay is applied to each covered mail order prescription charge and is shown on the Schedule of Benefits. The copay is not a covered expense under the Medical Expense Benefit. Any one prescription is limited to a ninety (90) day supply.

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COVERED PRESCRIPTION DRUGS

1. Drugs prescribed by a physician that require a prescription either by federal or state law, except injectables (other than insulin) and drugs excluded by the Plan, unless otherwise specified.

2. Compounded prescriptions containing at least one prescription ingredient with a therapeutic quantity.

3. Insulin, insulin needles and syringes and diabetic supplies when prescribed by a physician.

4. Allergy serums.

5. Oral contraceptives, regardless of the reason prescribed.

6. Certain contraceptive devices.

7. Any other drug which, under the applicable state law, may be dispensed only upon the written prescription of a qualified prescriber.

8. Erectile dysfunction medications according to industry recommended standards.

LIMITS TO THIS BENEFIT

This benefit applies only when a covered person incurs a covered prescription drug charge. The covered drug charge for any one prescription will be limited to:

1. Refills only up to the number of times specified by a physician.

2. Refills up to one year from the date of order by a physician.

EXPENSES NOT COVERED

1. A drug or medicine that can legally be purchased without a written prescription. This does not apply to injectable insulin.

2. Devices of any type, even though such devices may require a prescription. These include, but are not limited to: therapeutic devices, artificial appliances, braces, support garments, or any similar device.

3. Immunization agents or biological sera, blood or blood plasma.

4. A drug or medicine labeled: “Caution - limited by federal law to investigational use.”

5. Experimental drugs and medicines, even though a charge is made to the covered person, including DESI drugs (drugs determined by the FDA as lacking substantial evidence of effectiveness).

6. Any charge for the administration of a covered prescription drug.

7. Any drug or medicine that is consumed or administered at the place where it is dispensed.

8. A drug or medicine that is to be taken by the covered person, in whole or in part, while hospital confined. This includes being confined in any institution that has a facility for dispensing drugs.

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9. A charge for prescription drugs which may be properly received without charge under local, state or federal programs.

10. A charge for hypodermic syringes and/or needles, injectables or any prescription directing administration by injection (other than insulin), unless otherwise specified.

11. A charge for infertility medication.

12. A charge for legend vitamins, except pre-natal legend vitamins and vitamins prescribed for a specific medical condition.

13. A charge for minerals.

14. A charge for fluoride supplements.

15. A charge for medications that are cosmetic in nature (i.e., treating hair loss, wrinkles, etc.).

16. A charge for growth hormones, except through the CareMark Specialty RX Program.

17. A charge for weight loss drugs.

18. A charge for Tretinoins.

19. A charge for non-legend drugs, other than as specifically listed herein.

20. A charge for Levonorgestrel (Norplant implants).

21. A charge for Hematinics.

Any prescription drug covered under the Prescription Drug Program will not be covered under the Medical Expense Benefit, except as specified in Medical Expense Benefit, Prescription Drugs.

CVS CAREMARK SPECIALTY PHARMACY PROGRAM

The Specialty Pharmacy Program is available for select specialty drugs including select injectible and oral medications including but not limited to, the following conditions:

1. Allergic Asthma

2. Crohn’s disease

3. Enzyme replacement for Lysosomal Storage Disorder

4. Gaucher disease

5. Growth hormone disorders

6. Hematopoietics

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7. Hemophilia, Von Willebrand disease and related bleeding disorders

8. Hepatitis C

9. Hormonal therapies

10. Immune deficiencies

11. Multiple Sclerosis

12. Oncology

13. Osteoarthritis

14. Psoriasis

15. Pulmonary Arterial Hypertension

16. Pulmonary disease

17. Renal disease

18. Respiratory Syncytial Virus

19. Rheumatoid Arthritis

20. Other Disorders

To take advantage of this program, the covered person will need to transfer the related prescription to Caremark. To transfer a prescription, call 1-800-237-2767. A representative of Caremark will call the covered person’s physician and take care of the appropriate paperwork.

NOTICE OF AUTHORIZED REPRESENTATIVE

The covered person may provide the plan administrator (or its designee) with a written authorization for an authorized representative to represent and act on behalf of a covered person and consent to release of information related to the covered person to the authorized representative with respect to a claim for benefits or an appeal. Authorization forms may be obtained from the Human Resource Department.

APPEALING A DENIED POST-SERVICE PRESCRIPTION DRUG CLAIM

The “named fiduciary” for purposes of an appeal of a denied Post-Service Prescription Drug Claim, as described in U. S. Department of Labor Regulations 2560.503-1 (issued November 21, 2000), is the claims processor (when there is no prior authorization for drugs) for medical/dental/vision claims (when prior authorization is required) Prescription Benefits Manager.

A covered person, or the covered person’s authorized representative, may request a review of a denied claim by making written request to the named fiduciary within one hundred eighty (180) calendar days from receipt of notification of the denial and stating the reasons the covered person feels the claim should not have been denied.

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The following describes the review process and rights of the covered person:

1. The covered person has a right to submit documents, information and comments.

2. The covered person has the right to access, free of charge, relevant information to the claim for benefits.

3. The review takes into account all information submitted by the covered person, even if it was not considered in the initial benefit determination.

4. The review by the named fiduciary will not afford deference to the original denial.

5. The named fiduciary will not be:

a. The individual who originally denied the claim, norb. Subordinate to the individual who originally denied the claim.

6. If original denial was, in whole or in part, based on medical judgment:

a. The named fiduciary will consult with a professional provider who has appropriate training and experience in the field involving the medical judgment; and

b. The professional provider utilized by the named fiduciary will be neither:(i.) An individual who was consulted in connection with the original denial of the claim, nor(ii.) A subordinate of any other professional provider who was consulted in connection with

the original denial.

7. If requested, the named fiduciary will identify the medical or vocational expert(s) who gave advice in connection with the original denial, whether or not the advice was relied upon.

NOTICE OF BENEFIT DETERMINATION ON A POST-SERVICE PRESCRIPTION DRUG CLAIM APPEAL

The plan administrator (or its designee) shall provide the covered person (or authorized representative) with a written notice of the appeal decision within sixty (60) calendar days of receipt of a written request for the appeal.

If the appeal is denied, the Notice of Appeal Decision will contain an explanation of the Decision, including:

1. The specific reasons for the denial.

2. Reference to specific Plan provisions on which the denial is based.

3. A statement that the covered person has the right to access, free of charge, relevant information to the claim for benefits.

4. If an internal rule, guideline, protocol or other similar criterion was relied upon, the Notice of Appeal Deci-sion will contain either:

a. A copy of that criterion, orb. A statement that such criterion was relied upon and will be supplied free of charge, upon request.

5. If the denial was based on medical necessity, experimental/investigational treatment or similar exclusion or limit, the Plan will supply either:

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a. An explanation of the scientific or clinical judgment, applying the terms of the Plan to the claimant’s medical circumstances, or

b. A statement that such explanation will be supplied free of charge, upon request.

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DENTAL EXPENSE BENEFIT

Subject to all the terms of the Plan, the Plan will pay a dental benefit for covered dental expenses. The dental benefit is a percentage of the Maximum Plan Allowance for covered dental expenses, as shown on the Schedule of Benefits.

PREDETERMINATION OF BENEFITS

"Predetermination of benefits" allows the patient to learn an estimate of the amount the Plan will pay for extensive work the dentist recommends before the work is performed. A dentist may file a dental claim form showing the services he recommends. The Dental Claims Processor will then pre-determine the dental benefits payable under the Plan. Payment will only be made for pre-determined services if the covered person receives dental treatment for which dental benefits are payable, remains eligible, and has not exceeded his Annual Dental Maximum. A dental claim form requesting a pre-determination may be submitted electronically. A covered person, however, is not required to seek a pre-determination for any dental treatment under the Plan.

DEDUCTIBLE

Individual Deductible

The individual deductible is the dollar amount of covered expense which each covered person must incur during each calendar year before the Plan pays applicable benefits. The individual deductible amount is shown on the Schedule of Benefits and does not apply toward diagnostic/preventive services.

COINSURANCE

The Plan pays a specified percentage of the Maximum Plan Allowance or MPA for covered expenses. That percentage is listed on the Schedule of Benefits. The covered person is responsible for the difference.

The Dental Claims Processor will only pay the Dental Benefits stated for each type of dental service set out in the Schedule of Benefits. Not all dental services are BENEFITS under this PLAN. Dental Benefits will only be provided for covered persons who are enrolled on the date of treatment. Dental Benefits will be determined based on the date services were rendered. Dental services must be provided by a Dentist or properly licensed employee of the Dentist. Dental services must be necessary and provided following generally accepted dental practice standards as determined by the dental profession to be a paid benefit. The Dental Claims Processor will pay allowable Dental Benefits based upon the percentages and subject to the maximum benefit as stated on the Schedule of Benefits. Such percentages will be applied to the lesser of the Maximum Plan Allowance (MPA) or the fees the Dentist charges for the services. Payments for covered expenses performed by Non-Participating Dentists will be sent to the participant. Non-Participating Dentists may balance-bill patients for the difference of their charges and the Dental Claims Processor’s payment; Participating Dentists shall not balance-bill patients for charges exceeding the MPA for covered benefits under this Plan.

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MAXIMUM BENEFIT

The maximum calendar year benefit payable on behalf of a covered person for covered dental expense is stated on the Schedule of Benefits. If the covered person's coverage under the Plan terminates and he subsequently returns to coverage under the Plan during the calendar year, the maximum benefit will be calculated on the sum of benefits paid by the Plan.

ALTERNATIVE TREATMENT

In the event the dentist recommends a particular course of treatment and a lower-cost alternative would be as effective, benefits shall be limited to the lower-cost alternative. Any balance remaining, as a result of the covered person's choice to obtain the higher-cost treatment will be the covered person's responsibility.

DENTAL INCURRED DATE

A dental procedure will be deemed to have commenced on the date the covered dental expense is incurred, except as follows:

1. For endodontic treatment, on the date the pulp chamber is opened.

COVERED DENTAL EXPENSES

Subject to the limitations and exclusions, covered dental expenses shall include the necessary services, supplies, or treatment listed below and on the following pages. No dental benefit will be paid for any dental service, supply or treatment which is not on the following list of covered dental expenses.

Class I—Diagnostic and Preventive Dental Services

1. Routine periodic and specialty oral examination: Initial or periodic, limited to twice per calendar year.

2. Prophylaxis: Scaling and cleaning of teeth, limited to twice per calendar year.

3. Dental x-rays as follows:

a. Bitewing and periapical X-rays as required.b. Panorex and/or full mouth series, limited to once in any five (5) year period.

4. Topical application of fluoride, limited to once per calendar year for dependent children to age nineteen (19).

5. Topical application of sealant, limited to once per tooth for dependent children to age sixteen (16).

Class I—Diagnostic and Preventive Dental Services Limitations and Exclusions

a. DDAR will pay for two (2) oral examinations and cleanings per person per calendar year.b. Diagnostic casts, photographs, and cephalometric films are not covered.c. Full-mouth debridement is limited to once in a lifetime.d. DDAR will pay for full mouth x-rays once within five (5) years. A combination of periapical and

bitewing x-rays (ten [10] or more films) or a panoramic film and additional x-rays make up a full mouth series.

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e. A sealant is a benefit only on the unrestored, decay free chewing surface (occlusal surface) of the maxillary (upper) and mandibular (lower) first and second molars. Sealants are a benefit for dependent children to age sixteen (16). Sealants are payable once per tooth.

f. Preventative control programs (oral hygiene instructions, carries susceptibility tests, dietary control, tobacco counseling, etc.) are not a covered benefit.

g. DDAR will pay for one (1) topical application of fluoride in a calendar year for dependent children to age nineteen (19). Fluoride rinses or self-applied fluorides are not a covered benefit.

h. DDAR will not pay for adult cleanings for covered person(s) to age fourteen (14).i. Pulp vitality tests are payable per visit, not per tooth, and only for the diagnosis of emergency

conditions.

Class II—Basic Dental Services

1. Palliative emergency treatment—Minor emergency treatment for relief of pain as needed by the covered person.

2. Fillings—Amalgam (silver) and composite/resin (white) fillings (Composites are not a covered benefit on molars. See “b” below under Class II—Basic Dental Services Limitations and Exclusions.)

3. Endodontics—Includes pulpal therapy; root canal filling.

4. Extractions—Simple extractions.

5. Oral Surgery—Oral surgery, including pre- and post-operative care and surgical extractions, except TMJ surgery.

6. Space Maintainers—For prematurely lost teeth of eligible dependent children to age thirteen (13).

7. Stainless Steel Crowns—Used as a restoration to natural teeth for dependent children to age sixteen (16) when teeth cannot be restored with a filling material.

Class II—Basic Dental Services Limitations and Exclusions

a. Palliative emergency treatment is payable on a per visit basis, once on the same date.b. Restorative benefits are allowed once per surface per tooth in a twenty-four (24) month period.

This is allowed irrespective of the number of combinations of procedures requested or performed. Composites on molars are not covered. An amalgam allowance will be made for molars with any fee difference the responsibility of the patient.

c. Payment for root canal treatment includes charges for temporary restorations. Root canal treatment is limited to once in a lifetime, per tooth by the same dentist or dental office. Retreatment of root canal by the same dentist or dental office will be considered after twenty-four (24) months have lapsed since initial treatment. Root canals on deciduous teeth are not a benefit, unless there is no permanent successor. Pulpal therapy is limited to primary teeth and therapeutic pulpotomy is limited to primary teeth once in a lifetime.

d. Extractions, surgical extractions, root removal, alveoplasty, surgical exposure of impacted or unerupted teeth, tooth reimplantation and/or stabilization, transseptal fiberotomy, and oroantral fistula closure are limited to once per lifetime.

e. Charges for general anesthesia/intravenous sedation are not covered except when administered in conjunction with covered oral surgery, excluding single tooth extractions (ADA procedure code 7140) and for children three (3) years of age and under.

f. Analgesia, anxiolysis, inhalation of nitrous oxide, therapeutic drug injection, other drugs and/or medicines, and desensitizing medicines are not covered.

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g. Composite resin crowns are not a benefit on primary teeth. A stainless steel crown allowance will be made with any fee difference the responsbility of the patient.

h. A space maintainer is a benefit when used to replace prematurely lost or extracted teeth for children to age thirteen (13), limited to once in a sixty (60) consecutive month period. Recementation of a space mainainer is limited to once in five (5) years. Recementation of a space maintainer within six (6) months of the seating date is part of the original procedure. A space maintainer is not considered an orthodontic appliance.

i. DDAR will not pay for the replacement of a stainless steel crown within a sixty (60) month period of the initial placement.

j. Treatment of complications (post-surgical) or unusual circumstances are a benefit once in three (3) months (i.e. treatment of a dry-socket).

General Limitations and Exclusions

DDAR does not pay benefits for the following:

1. Benefits or services for injuries or conditions covered under Worker’s Compensation or Employer’s Liability Laws. Benefits or services available from any federal or state government agency; municipality, county, other political subdivision; or community agnecy; or from any foundation or similar entity.

2. Charges for services or supplies received as a result of dental disease, defect, or injury due to an act of war, declared or undeclared.

3. Charges for services or supplies for which no charge is made that the covered person is legally obligated to pay. Charges for which no charge would be made in the absence of dental coverage.

4. Charges for treatment by other than a licensed dentist except that a licensed hygienist may perform services in accordance with applicable law. Services must be under the supervision and guidance of the licensed dentist in accordance with generally accepted dental standards.

5. Charges for the completion of forms and/or submission of supportive documentation required by DDAR for a benefit determination. A charge for these services is not to be made to a DDAR-covered person by a participating dentist.

6. Benefits to correct congenital or developmental malformations.7. Services for the purpose of improving appearance when form and function are

satisfactory, and there is insufficient pathological condition evident to warrant the treatment (cosmetic dentistry).

8. Benefits for services or appliances started prior to the date the patient became eligible under this plan.

9. Services with respect to diagnosis and treatment of disturbances of the temporomandibular joint (TMJ).

10. Services for increasing the vertical dimension or for restoring tooth structure lost by attrition, for rebuilding or maintaining occlusal services, or for stabilizing the teeth.

11. Experimental and/or investigational services, supplies, care and treatment which does not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards or a reasonably substantial, qualified, responsible, relevant segment of the medical and dental community or government oversight agencies at the time services were rendered. The Claims Administrator must make an independent evaluation of the experimental or non-experimental standings of specific technologies. The Claims Administrator’s decision will be final and binding.

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Drugs are considered experimental if they are not commercially available for purchase and/or are not approved by the Food and Drug Administration for general use.

12. Implant techniques and procedures related to implants.13. Charges for replacement of lost, missing, or stolen appliances/devices.14. Charges for services when a claim is received for payment more than twelve

(12) months after services are rendered.15. Charges for complete occlusal adjustments, occlusal guards, occlusion analysis,

enamel microabrasion, odontoplasty, bleaching and athletic mouthguards.16. Specialized techniques that entail procedure and process over and above that

which is normally adequate. Any additional fee is the patient’s responsibility.17. Behavior management.18. Those services and benefits excluded by the rules and regulations of DDAR,

including DDAR’s processing policies.19. Removable appliances for control of harmful habits, including but not limited to

tongue thrust appliances.20. Charges for general anesthesia/intravenous sedation are not covered except

when administered in conjunction with covered oral surgery, excluding single tooth extractions (ADA procedure code 7140) and for children three (3) years of age and under.

21. Procedures that do not comply with DDAR’s guidelines.22. Charges for precision attachments, provisional splinting, desensitizing

medicines, home care medicines, premedications, stress breakers, coping, office visits during or after regularly scheduled hours, case presentations and hospital-related services.

23. All other benefits and services not specifically covered by the Plan.

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VISION EXPENSE BENEFIT

Vision benefits will be paid for the charges for covered vision expenses for covered persons as shown on the Schedule of Benefits. The benefits will apply when charges are incurred for vision care by a legally licensed physician or professional provider.

COVERED VISION EXPENSES

The Plan provides coverage for services, supplies and treatment for the following:

1. One (1) examination and refraction for each covered person per calendar year limited to the maximum benefit as specified in the Vision Schedule of Benefits.

2. Corrective lenses/frames or contacts limited to the maximum benefit per calendar year as specified in the Vision Schedule of Benefits.

VISION EXCLUSIONS

In addition to Plan Exclusions, no benefit will be provided under this Plan for vision expenses incurred by a covered person for the following:

1. Services or supplies required as a condition of employment or by any governmental body.

2. Sunglasses (plain or prescription), safety lenses, or goggles.

3. Medical or surgical care of the eye.

4. Any lenses not prescribed by a legally licensed physician or optometrist.

5. Any service performed or supplies provided for special procedures such as orthoptics or any aids for sub-normal vision.

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PLAN EXCLUSIONSThe Plan will not provide benefits for any of the items listed in this section, regardless of medical necessity or recommendation of a physician or professional provider.

1. Charges for services, supplies or treatment from any hospital owned or operated by the United States government or any agency thereof or any government outside the United States, or charges for services, treatment or supplies furnished by the United States government or any agency thereof or any government outside the United States, unless payment is legally required.

2. Charges for an injury sustained or illness contracted while on active duty in military service, unless payment is legally required.

3. Charges for services, treatment or supplies for treatment of illness or injury which is caused by or attributed to by war or any act of war, participation in a riot, civil disobedience or insurrection. "War" means declared or undeclared war, whether civil or international, or any substantial armed conflict between organized forces of a military nature.

4. Employees: Treatment or service due to illness or injury which occurred from any act for wage or profit provided the charges for the illness or injury are reimbursed by a policy of Workers’ Compensation Insurance; or

Dependents: Treatment or services due to illness or injury which is covered by Workers’ Compensation Insurance or which occurred from any act for wage or profit.

5. Charges in connection with any illness or injury arising out of or in the course of any employment intended for wage or profit, including self-employment.

6. Charges made for services, supplies and treatment which are not medically necessary for the treatment of illness or injury, or which are not recommended and approved by the attending physician, except as specifically stated herein, or to the extent that the charges exceed customary and reasonable amount or exceed the negotiated rate as applicable.

7. Charges in connection with any illness or injury of the covered person resulting from or occurring during commission or attempted commission of a criminal battery or felony by the covered person if the covered person is charged with such crime. This exclusion will not apply to illness and/or injury sustained due to a medical condition (physical or mental) or domestic violence.

8. To the extent that payment under this Plan is prohibited by any law of any jurisdiction in which the covered person resides at the time the expense is incurred.

9. Charges for services rendered and/or supplies received prior to the effective date or after the termination date of a person's coverage, except as specifically provided herein.

10. Any services, supplies or treatment for which the covered person is not legally required to pay; or for which no charge would usually be made; or for which such charge, if made, would not usually be collected if no coverage existed; or to the extent the charge for the care exceeds the charge that would have been made and collected if no coverage existed.

11. Charges for services, supplies or treatment that are considered experimental/investigational.

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12. Charges incurred outside the United States if the covered person traveled to such a location for the sole purpose of obtaining services, supplies or treatment.

13. Charges for services, supplies or treatment rendered by any individual who is a close relative of the covered person or who resides in the same household as the covered person.

14. Charges for services, supplies or treatment rendered by physicians or professional providers beyond the scope of their license; for any treatment, confinement or service which is not recommended by or performed by an appropriate professional provider.

15. Charges for illnesses or injuries suffered by a covered person due to the action or inaction of any party if the covered person fails to provide information as specified in Subrogation.

16. Claims not submitted within the Plan's filing limit deadlines as specified in Claim Filing Procedures.

17. Charges for telephone consultations, completion of claim forms, charges associated with missed appointments.

18. Charges for drugs, devices, supplies, treatments, procedures or services that are considered experimental/investigational by the Plan. The Plan will consider a drug, device, supply, treatment, procedure or service to be “experimental” or “investigative”:

a. if, in the case of a device or supply, the device or supply cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug, device or supply is furnished; or

b. if the drug, device, supply, treatment, procedure or service, or the patient’s informed consent document utilized with respect to the drug, device, supply, treatment, procedure or service was reviewed and approved by the treating facility’s institutional review board or other body serving a similar function, or if federal law requires such review or approval; or

c. if the plan sponsor (or its designee) determines in its sole discretion that the drug, device, supply, treatment, procedure or service is the subject of on-going Phase I or Phase II clinical trials; is the research, experimental, study or investigational arm of on-going Phase III clinical trials, or is otherwise under study to determine maximum tolerated dose, toxicity, safety or efficacy, however, a drug, device, supply, treatment, procedure or service that meets the standards set in the section Medical Expense Benefit, Off-Label Drug Use or Phase III Oncology Clinical Trials will not be deemed experimental or investigational solely by reason of this subparagraph; or

d. if the plan sponsor (or its designee) determines in its sole discretion based on documentation in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature that the prevailing opinion among experts regarding the drug, device, supply, treatment, procedure or service is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety or efficacy.

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ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE

This section identifies the Plan's requirements for a person to participate in the Plan.

EMPLOYEE ELIGIBILITY

An Employee is defined as a Bishop, ministerial member, full-time lay pastor or layperson employed by The United Methodist Church or an Annual Conference, local Church, or an agency or institution of such Church.

You are eligible if you are a:

1. Full-Time Active Employee of participating Annual Conferences, local churches, agencies, or institutions of The United Methodist Church. (Non-Clergy employees who perform active work thirty (30) or more hours per week are considered full-time Employees.)

2. Retired Employee of the above participating groups.

3. Surviving Spouse of a deceased employee who was an active employee at time of death.

A Retired Employee is defined as a former Employee retired by a participating group who is receiving a pension financed by the Employer and was covered under the Plan prior to retirement.

Surviving Spouse of a deceased employee of the above participating groups.

A Surviving Spouse is defined as the wife or husband of a deceased Employee of a participating group included under this Plan who was covered under the Plan prior to the employee’s death and/or retirement.

Retired employees may continue coverage by paying the applicable contribution for employee and/or dependent coverage. While the employer expects retiree coverage to continue, the employer reserves the right to modify or discontinue retiree coverage or any other provision of the Plan at any time.

EMPLOYEE ENROLLMENT

An employee must file a written application with the employer for coverage hereunder for himself within thirty-one (31) days of becoming eligible for coverage. The employee shall have the responsibility of timely forwarding to the employer all applications for enrollment hereunder.

EMPLOYEE(S) EFFECTIVE DATE

Eligible employees, as described in Employee Eligibility, are covered under the Plan on the first day of full-time employment.

DEPENDENT(S) ELIGIBILITY

The following describes dependent eligibility requirements. The employer will require proof of dependent status.

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1. The term "spouse" means the spouse of the employee under a legally valid existing marriage between person’s of the opposite sex, unless court ordered separation exists. This also includes a valid marriage entered into in another state between persons of the opposite sex, unless court ordered separation exists.

2. The term "child" means the employee's natural child, stepchild, legally adopted child, child placed for adoption, foster child, and a child for whom the employee or covered spouse has been appointed legal guardian, provided the child is less than twenty-six (26) years of age and is not eligible to enroll in any other employer sponsored group health plan, other than through a parent.

3. An eligible child shall also include any other child of an employee or their spouse who is recognized in a Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN) which has been issued by any court judgment, decree, or order as being entitled to enrollment for coverage under this Plan. Such child shall be referred to as an alternate recipient. Alternate recipients are eligible for coverage regardless of whether the employee elects coverage for himself. An application for enrollment must be submitted to the employer for coverage under this Plan. The employer/plan administrator shall establish written procedures for determining whether a medical child support order is a QMCSO or NMSN and for administering the provision of benefits under the Plan pursuant to a valid QMCSO or NMSN. Within a reasonable period after receipt of a medical child support order, the employer/plan administrator shall determine whether such order is a QMCSO, as defined in Section 609 of ERISA, or a NMSN, as defined in Section 401 of the Child Support Performance and Incentive Act of 1998.

The employer/plan administrator reserves the right, waivable at its discretion, to seek clarification with respect to the order from the court or administrative agency which issued the order, up to and including the right to seek a hearing before the court or agency.

4. A dependent child who was covered under the Plan prior to reaching the maximum age limit of twenty-six (26) years and who lives with the employee, is unmarried, incapable of self-sustaining employment and dependent upon the employee for support due to a mental and/or physical disability, will remain eligible for coverage under this Plan beyond the date coverage would otherwise terminate.

Proof of incapacitation must be provided within thirty-one (31) days of the child's loss of eligibility and thereafter as requested by the employer or claims processor, but not more than once every two (2) years. Eligibility may not be continued beyond the earliest of the following:

a. Cessation of the mental and/or physical disability;b. Failure to furnish any required proof of mental and/or physical disability or to submit to any

required examination.

Every eligible employee may enroll eligible dependents. However, if both the husband and wife are employees, they may choose to have one covered as the employee, and the spouse covered as the dependent of the employee, or they may choose to have both covered as employees. Eligible children may be enrolled as dependents of one spouse, but not both.

DEPENDENT ENROLLMENT

An employee must file a written application with the employer for coverage hereunder for his eligible dependents within thirty-one (31) days of becoming eligible for coverage; within thirty (30) days of marriage or the acquiring of children; and within ninety (90) days of the birth of a child. The employee shall have the responsibility of timely forwarding to the employer all applications for enrollment hereunder.

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DEPENDENT(S) EFFECTIVE DATE

Eligible dependent(s), as described in Eligibility, will become covered under the Plan on the later of the dates listed below, provided the employee has enrolled them in the Plan within thirty-one (31) days of meeting the Plan's eligibility requirements.

1. The date the employee's coverage becomes effective.

2. The date the dependent is acquired, provided any required contributions are made and the employee has applied for dependent coverage within thirty (30) days of the date acquired.

3. Newborn children shall be covered from birth, regardless of confinement, provided the employee has applied for dependent coverage within ninety (90) days of birth.

4. Coverage for a newly or to be adopted child shall be effective on the date the child is placed for adoption.

SPECIAL ENROLLMENT PERIOD (OTHER COVERAGE)

An employee or dependent who did not enroll for coverage under this Plan because he was covered under other group coverage or had health insurance coverage at the time he was initially eligible for coverage under this Plan, may request a special enrollment period if he is no longer eligible for the other coverage. Special enrollment periods will be granted if the individual's loss of eligibility is due to:

1. Termination of the other coverage (including exhaustion of COBRA benefits)

2. Cessation of employer contributions toward the other coverage

3. Legal separation or divorce

4. Termination of other employment or reduction in number of hours of other employment

5. Death of dependent or spouse

6. Cessation of other coverage because employee or dependent no longer resides or works in the service area and no other benefit package is available to the individual.

7. Cessation of dependent status under other coverage and dependent is otherwise eligible under employee’s Plan.

8. An incurred claim that would exceed the other coverage’s maximum benefit limit. The maximum benefit limit is all-inclusive and means that no further benefits are payable under the other coverage because the specific total benefit pay out maximum has been reached under the other coverage. The right for special enrollment continues for thirty (30) days after the date the claim is denied under the other coverage.

The Schedule of Benefits contains a separate annual maximum benefit. The Schedule of Benefits may also contain separate maximum benefit limitations for specified conditions and/or services. Any separate maximum benefit will include all such benefits paid by the Plan for the covered person during any and all periods of coverage under this Plan. No more than the maximum benefit will be paid for any covered person while covered by this Plan.

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Notwithstanding any provision of the Plan to the contrary, all benefits received by an individual under any benefit option, package or coverage under the Plan shall be applied toward the Essential Health Benefits/non-Essential Health Benefits maximum benefit paid by the Plan for any one covered person for such option, package or coverage under the Plan, and also toward the Essential Health Benefits/non-Essential Health Benefits maximum benefit under any other options, packages or coverages under the Plan in which the individual may participate in the future.


The end of any extended benefits period, which has been provided due to any of the above, will also be considered a loss of eligibility.

However, loss of eligibility does not include a loss due to failure of the individual to pay premiums or contributions on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the other coverage).

The employee or dependent must request the special enrollment and enroll no later than thirty (30) days from the date of loss of other coverage.

The effective date of coverage as the result of a special enrollment shall be the date of loss of other coverage.

SPECIAL ENROLLMENT PERIOD (DEPENDENT ACQUISITION)

An employee who is currently covered or not covered under the Plan, but who acquires a new dependent may request a special enrollment period for himself and all his/her eligible dependents that are otherwise eligible for coverage.

For the purposes of this provision, the acquisition of a new dependent includes:- marriage- birth of a dependent child- adoption or placement for adoption of a dependent child

The employee must request the special enrollment within thirty (30) days of the acquisition of the dependent.

The effective date of coverage as the result of a special enrollment shall be:

1. in the case of marriage, the date of such marriage;

2. in the case of a dependent's birth, the date of such birth;

3. in the case of adoption or placement for adoption, the date of such adoption or placement for adoption.

SPECIAL ENROLLMENT PERIOD (CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) REAUTHORIZATION ACT OF 2009)

Effective January 1, 2009, this Plan intends to comply with the Children's Health Insurance Program Reauthorization Act of 2009.

An employee who is currently covered or not covered under the Plan may request a special enrollment period for himself, if applicable, and his dependent. Special enrollment periods will be granted if:

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1. the individual's loss of eligibility is due to termination of coverage under a state children's health insurance program or Medicaid; or,

2. the individual is eligible for any applicable premium assistance under a state children's health insurance program or Medicaid.

The employee or dependent must request the special enrollment and enroll no later than sixty (60) days from the date of loss of other coverage or from the date the individual becomes eligible for any applicable premium assistance.

The effective date of coverage as the result of a special enrollment shall be the first day of the first calendar month following the plan administrator's receipt of the completed enrollment form.

SPECIAL ENROLLMENT PERIOD (PATIENT PROTECTION AND AFFORDABLE CARE ACT)

Effective for Plan years renewing after September 23, 2010, and pursuant to the Patient Protection and Affordable Care Act, an employee who is currently covered or not covered under the Plan may enroll for coverage for himself and his dependent. Special enrollment will be granted if:

1. the dependent’s coverage under this Plan ended or the dependent was not eligible or was denied coverage under this Plan because the Plan did not provide coverage to age twenty-six (26).

2. the dependent is not eligible to enroll in any other employer sponsored group health plan, other than through a parent.

The employee or dependent must enroll no later than thirty (30) days from receipt of notice of the special enrollment period.

OPEN ENROLLMENT

Open enrollment is the period designated by the employer during which the employee may change benefit plans or enroll in the Plan if he did not do so when first eligible or does not qualify for a special enrollment period. An open enrollment will be permitted once in each calendar year during the month of September. A covered employee who fails to make an election or to change enrollment during the open enrollment period will automatically retain his or her present coverage.

During this open enrollment period, an employee and his dependents that are covered under this Plan or covered under any employer sponsored health plan may elect coverage or change coverage under this Plan for himself and his eligible dependents. An employee must make written application as provided by the employer during the open enrollment period to change benefit plans.

Any person enrolling in this Plan for the first time at open enrollment (not transferring from another employer-sponsored health plan) will be treated as a late enrollee.

The effective date of coverage as the result of an open enrollment period will be the following October 1st.

Except for a status change listed below or as described below in Effect of an HMO Plan, the open enrollment period is the only time an employee may change benefit options or modify enrollment. Status changes include:

1. Change in family status. A change in family status shall include only:

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a. Change in employee's legal marital status;b. Change in number of dependents;c. Termination or commencement of employment by the employee, spouse or dependent;d. Change in work schedule;e. Dependent satisfies (or ceases to satisfy) dependent eligibility requirements;f. Change in residence or worksite of employee, spouse or dependent.

2. Significant change in the cost of coverage under the employer's group medical plan.

3. Cessation of required contributions.

4. Taking or returning from a leave of absence under the Family and Medical Leave Act.

5. Significant change in the health coverage of the employee or spouse attributable to the spouse's employment.

6. A Special Enrollment Period as mandated by the Health Insurance Portability and Accountability Act.

7. A court order, judgment or decree.

8. Entitlement to Medicare or Medicaid or enrollment in a state child health insurance program (CHIP).

9. A COBRA qualifying event.

Effect of an HMO Plan

If an employee transfers from an HMO plan sponsored by the employer to this Plan under circumstances described in 1, 2 or 3 below, the coverage under this Plan will become effective on the day following the date the HMO coverage terminates.

1. During the open enrollment period; or

2. Because the HMO ceased operation; or

3. Because the employee changed residence and is no longer eligible for coverage under the HMO.

The pre-existing conditions provisions will not apply to those persons whose coverage is being transferred from the HMO plan, provided enrollment occurs within thirty (30) days. These provisions will not be waived if an employee transfers coverage to this Plan at any other time than specified in 1, 2, or 3.

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PRE-EXISTING CONDITIONSA pre-existing condition is an illness or injury that existed within one hundred eighty (180) days before the covered person's enrollment date for coverage under this Plan. An illness or injury is considered to have existed when the covered person:

1. Sought or received professional advice for that illness or injury, or

2. Received medical care or treatment for that illness or injury, or

3. Received medical supplies, drugs, or medicines for that illness or injury.

Benefits will be provided for pre-existing conditions after the completion of a period of 365 days (545 days for a late enrollee) from the covered person's enrollment date for coverage under this Plan, except pre-existing for infertility of a late enrollee shall be limited to three hundred and sixty-five (365) days only. The enrollment date shall mean the first day of any applicable service waiting period or the date of hire or, in the case of a Special Enrollment Period or Open Enrollment Period, the date the enrollment form is executed.

This pre-existing condition limitation shall not apply to a child born to or placed for adoption under the Special Enrollment provisions of the Plan for dependent acquisitions, nor to pregnancy under any circumstances. Pre-existing conditions will be waived for a minister and eligible dependents who have been given a first-time appointment in the Arkansas Conferences, if enrollment is made within thirty (30) days of the appointment.

This pre-existing condition limitation shall not apply to an employee or dependent less than nineteen (19) years of age, or to pregnancy under any circumstances.

Precertification from the Health Care Management Organization does not constitute Plan liability for any pre-existing condition charges during this pre-existing condition limitation period.

The covered person has a right to appeal the determination of coverage for pre-existing conditions. See Claim Filing Procedures.

For the purpose of determining whether this pre-existing condition provision of the Plan will be applied to claims for any individual, the plan administrator will look not only to the period of time the individual has been covered under this Plan, but also to any period of previous creditable coverage the individual has earned. Creditable coverage shall include, but is not limited to, coverage the individual may have had under a prior employer's benefit plan or COBRA, individual or group insurance, Medicare or Medicaid, a state risk pool, or CHAMPUS/TRICARE. Other types of coverage may also be considered creditable coverage. However, creditable coverage will only be applied to this Plan's pre-existing condition time periods if there has been no break in coverage of the individual for sixty-three (63) days or more. If there has been a break in coverage of sixty-three (63) days or more, the plan administrator will not apply previous coverage towards this Plan's pre-existing condition limitation. Waiting periods for coverage do not count as a break in coverage.

It is the employee's responsibility to provide the plan administrator with evidence of creditable coverage. Such evidence may be in the form of a Certificate of Coverage or in any other form acceptable to the plan administrator.

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TERMINATION OF COVERAGEExcept as provided in the Plan's Continuation of Coverage (COBRA) or Extension of Benefits provision, coverage will terminate on the earliest of the following dates:

TERMINATION OF EMPLOYEE COVERAGE

1. The date the employer terminates the Plan and offers no other group health plan.

2. The date the employee ceases to meet the eligibility requirements of the Plan.

3. The date employment terminates, as defined by the employer's personnel policies.

4. The date the employee becomes a full-time, active member of the armed forces of any country.

5. The date the employee ceases to make any required contributions.

If an employee elects to become covered under another employer-sponsored health plan, coverage under this Plan will terminate on the day before the effective date of the other coverage. Any provisions that would extend or continue benefits beyond that date will not apply.

TERMINATION OF DEPENDENT(S) COVERAGE

1. The date the employer terminates the Plan and offers no other group health plan.

2. The date the employee's coverage terminates. However, if the employee remains eligible for the Plan, but elects to discontinue coverage, coverage may be extended for alternate recipients.

3. The date such person ceases to meet the eligibility requirements of the Plan.

4. The date the employee ceases to make any required contributions on the dependent's behalf.

5. The date the dependent becomes a full-time, active member of the armed forces of any country.

6. The date the Plan discontinues dependent coverage for any and all dependents.

7. The date the dependent becomes eligible as an employee.

LEAVE OF ABSENCE

Coverage may be continued for a limited time, contingent upon payment of any required contributions for employees and/or dependents, when the employee is on an authorized leave of absence from the employer. In no event will coverage continue for more than three (3) months after the employee's active service ends.

LAYOFF

Coverage may be continued for a limited time, contingent upon payment of any required contributions for employees and/or dependents, when the employee is subject to an employer layoff. In no event will coverage continue for more than three (3) months after the employee's active service ends.

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FAMILY AND MEDICAL LEAVE ACT (FMLA)

Eligible Leave

An employee who is eligible for unpaid leave and benefits under the terms of the Family and Medical Leave Act of 1993 (FMLA), as amended, has the right to continue coverage under this Plan for up to twelve (12) weeks (twenty-six (26) weeks in certain circumstances). Employees should contact the employer to determine whether they are eligible under FMLA.

Contributions

During this leave, the employer will continue to pay the same portion of the employee's contribution for the Plan. The employee shall be responsible to continue payment for eligible dependent's coverage and any remaining employee contributions. If the covered employee fails to make the required contribution during a FMLA leave within thirty (30) days after the date the contribution was due, the coverage will terminate effective on the date the contribution was due.

Reinstatement

If coverage under the Plan was terminated during an approved FMLA leave, and the employee returns to active work immediately upon completion of that leave, Plan coverage will be reinstated on the date the employee returns to active work as if coverage had not terminated, provided the employee makes any necessary contributions and enrolls for coverage within thirty (30) days of his return to active work.

Repayment Requirement

The employer may require employees who fail to return from a leave under FMLA to repay any contributions paid by the employer on the employee's behalf during an unpaid leave. This repayment will be required only if the employee's failure to return from such leave is not related to a "serious health condition," as defined in FMLA, or events beyond the employee's control.

EMPLOYEE REINSTATEMENT

Employees and eligible dependents who lost coverage due to an approved leave of absence, layoff, or separation of service from the employer are eligible for reinstatement of coverage as follows:

1. Reinstatement of coverage is available to employees and dependents that were previously covered under the Plan.

2. Rehire must occur within three (3) months of separation from service.

3. The employee must submit the completed application for enrollment to the employer within thirty-one (31) days of rehire.

4. Coverage shall be effective from the date of rehire. Prior benefits and limitations, such as deductible, maximum benefit, pre-existing condition waiting period, shall be applied with no break in coverage.

If the provisions of (1) through (3) above are not met, the Plan's provisions for eligibility and application for enrollment shall apply.

An employee who returns to work after three (3) months of an approved leave of absence, layoff, or separation of service will be considered a new employee for purposes of eligibility and will be subject to all eligibility

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requirements, including all requirements relating to the effective date of coverage and the pre-existing condition limitations.

An employee who elects to continue coverage and return to work before continuation coverage terminates will retain the same employment status as prior to the event that qualified him or her for continuation coverage and no new pre-existing condition limitation, or eligibility waiting period will again apply.

CERTIFICATES OF COVERAGE

The plan administrator shall provide each terminating covered person with a Certificate of Coverage, certifying the period of time the individual was covered under this Plan. For employees with dependent coverage, the certificate provided may include information on all covered dependents. This Plan intends to at all times comply with the provisions of the Health Insurance Portability and Accountability Act of 1996.

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CONTINUATION OF COVERAGEIn order to voluntarily comply with federal regulations, this Plan includes a continuation of coverage option for certain individuals whose coverage would otherwise terminate. The following is intended to voluntarily comply with the Public Health Services Act. This continuation of coverage may be commonly referred to as "COBRA coverage" or "continuation coverage."

The coverage which may be continued under this provision consists of health coverage. It does not include life insurance benefits, accidental death and dismemberment benefits, or income replacement benefits. Health coverage includes medical, prescription drug, dental and vision benefits as provided under the Plan.

QUALIFYING EVENTS

Qualifying events are any one of the following events that would cause a covered person to lose coverage under this Plan or cause an increase in required contributions, even if such loss of coverage or increase in required contributions does not take effect immediately, and allow such person to continue coverage beyond the date described in Termination of Coverage:

1. Death of the employee.

2. The employee's termination of employment (other than termination for gross misconduct), or reduction in work hours to less than the minimum required for coverage under the Plan. This event is referred to below as an "18-Month Qualifying Event."

3. Divorce or legal separation from the employee.

4. The employee's entitlement to Medicare benefits under Title XVIII of the Social Security Act, if it results in the loss of coverage under this Plan.

5. A dependent child no longer meets the eligibility requirements of the Plan.

6. The last day of leave under the Family and Medical Leave Act of 1993, or an earlier date on which the employee informs the employer that he or she will not be returning to work.

7. The call-up of an employee reservist to active duty.

8. A covered retiree and their covered dependents whose benefits were substantially eliminated within one (1) year of the employer filing for Chapter 11 bankruptcy.

NOTIFICATION REQUIREMENTS

1. When eligibility for continuation of coverage results from a spouse being divorced or legally separated from a covered employee, or a child's loss of dependent status, the employee or dependent must submit a completed Qualifying Event Notification form to the plan administrator (or its designee) within sixty (60) days of the latest of:

a. The date of the event;b. The date on which coverage under this Plan is or would be lost as a result of that event; orc. The date on which the employee or dependent is furnished with a copy of this Plan Document.

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A copy of the Qualifying Event Notification form is available from the plan administrator (or its designee). In addition, the employee or dependent may be required to promptly provide any supporting documentation as may be reasonably requested for purposes of verification. Failure to provide such notice and any requested supporting documentation will result in the person forfeiting their rights to continuation of coverage under this provision.

Within fourteen (14) days of the receipt of a properly completed Qualifying Event Notification, the plan administrator (or its designee) will notify the employee or dependent of his rights to continuation of coverage, and what process is required to elect continuation of coverage. This notice is referred to below as "Election Notice."

2. When eligibility for continuation of coverage results from any qualifying event under this Plan other than the ones described in Paragraph 1 above, the employer must notify the plan administrator (or its designee) not later than thirty (30) days after the date on which the employee or dependent loses coverage under the Plan due to the qualifying event. Within fourteen (14) days of the receipt of the notice of the qualifying event, the plan administrator (or its designee) will furnish the Election Notice to the employee or dependent.

3. In the event it is determined that an individual seeking continuation of coverage (or extension of continuation coverage) is not entitled to such coverage, the plan administrator (or its designee) will provide to such individual an explanation as to why the individual is not entitled to continuation coverage. This notice is referred to here as the "Non-Eligibility Notice." The Non-Eligibility Notice will be furnished in accordance with the same time frame as applicable to the furnishing of the Election Notice.

4. In the event an Election Notice is furnished, the eligible employee or dependent has sixty (60) days to decide whether to elect continued coverage. Each person who is described in the Election Notice and was covered under the Plan on the day before the qualifying event has the right to elect continuation of coverage on an individual basis, regardless of family enrollment. If the employee or dependent chooses to have continuation coverage, he must advise the plan administrator (or its designee) of this choice by returning to the plan administrator (or its designee) a properly completed Election Notice not later than the last day of the sixty (60) day period. If the Election Notice is mailed to the plan administrator (or its designee), it must be postmarked on or before the last day of the sixty (60) day period. This sixty (60) day period begins on the later of the following:

a. The date coverage under the Plan would otherwise end; orb. The date the person receives the Election Notice from the plan administrator (or its designee).

5. Within forty-five (45) days after the date the person notifies the plan administrator (or its designee) that he has chosen to continue coverage, the person must make the initial payment. The initial payment will be the amount needed to provide coverage from the date continued benefits begin, through the period in which the initial payment is made. Thereafter, payments for the continuation coverage are to be made monthly, and are due in advance, on the date specified by the plan administrator (or its designee).

COST OF COVERAGE

1. The Plan requires that covered persons pay the entire costs of their continuation coverage, plus a two percent (2%) administrative fee. Except for the initial payment (see above), payments must be remitted to the plan administrator (or its designee) by or before the first day of each period during the continuation period. The payment must be remitted on a timely basis in order to maintain the coverage in force.

2. For a person originally covered as an employee or as a spouse, the cost of coverage is the amount applicable to an employee if coverage is continued for himself alone. For a person originally covered as a

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child and continuing coverage independent of the family unit, the cost of coverage is the amount applicable to an employee.

WHEN CONTINUATION COVERAGE BEGINS

When continuation coverage is elected and the initial payment is made within the time period required, coverage is reinstated back to the date of the loss of coverage, so that no break in coverage occurs. Coverage for dependents acquired and properly enrolled during the continuation period begins in accordance with the enrollment provisions of the Plan.

FAMILY MEMBERS ACQUIRED DURING CONTINUATION

A spouse or dependent child newly acquired during continuation coverage is eligible to be enrolled as a dependent. The standard enrollment provision of the Plan applies to enrollees during continuation coverage. A dependent acquired and enrolled after the original qualifying event, other than a child born to or placed for adoption with a covered employee during a period of COBRA continuation coverage, is not eligible for a separate continuation if a subsequent event results in the person's loss of coverage.

EXTENSION OF CONTINUATION COVERAGE

1. In the event any of the following events occur during the period of continuation coverage resulting from an 18-Month Qualifying Event, it is possible for a dependent's continuation coverage to be extended:

a. Death of the employee.b. Divorce or legal separation from the employee.c. The child's loss of dependent status.

Written notice of such event must be provided by submitting a completed Additional Extension Event Notification form to the plan administrator (or its designee) within sixty (60) days of the latest of:

(i.) The date of that event;(ii.) The date on which coverage under this Plan would be lost as a result of that event if the first

qualifying event had not occurred; or(iii.) The date on which the employee or dependent is furnished with a copy of this Plan Document.

A copy of the Additional Extension Event Notification form is available from the plan administrator (or its designee). In addition, the dependent may be required to promptly provide any supporting documentation as may be reasonably required for purposes of verification. Failure to properly provide the Additional Extension Event Notification and any requested supporting documentation will result in the person forfeiting their rights to extend continuation coverage under this provision. In no event will any extension of continuation coverage extend beyond thirty-six (36) months from the later of the date of the first qualifying event or the date as of which continuation coverage began.

Only a person covered prior to the original qualifying event or a child born to or placed for adoption with a covered employee during a period of COBRA coverage may be eligible to continue coverage through an extension of continuation coverage as described above. Any other dependent acquired during continuation coverage is not eligible to extend continuation coverage as described above.

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2. A person who loses coverage on account of an 18-Month Qualifying Event may extend the maximum period of continuation coverage from eighteen (18) months to up to twenty-nine (29) months in the event both of the following occur:

a. That person (or another person who is entitled to continuation coverage on account of the same 18-Month Qualifying Event) is determined by the Social Security Administration, under Title II or Title XVI of the Social Security Act, to have been disabled before the sixtieth (60 th) day of continuation coverage; and

b. The disability status, as determined by the Social Security Administration, lasts at least until the end of the initial eighteen (18) month period of continuation coverage.

The disabled person (or his representative) must submit written proof of the Social Security Administration's disability determination to the plan administrator (or its designee) within the initial eighteen (18) month period of continuation coverage and no later than sixty (60) days after the latest of:

(i.) The date of the disability determination by the Social Security Administration;(ii.) The date of the 18-Month Qualifying Event;(iii.) The date on which the person loses (or would lose) coverage under this Plan as a result of the 18-

Month Qualifying Event; or(iv.) The date on which the person is furnished with a copy of this Plan Document.

Should the disabled person fail to notify the plan administrator (or its designee) in writing within the time frame described above, the disabled person (and others entitled to disability extension on account of that person) will then be entitled to whatever period of continuation he or they would otherwise be entitled to, if any. The Plan may require that the individual pay one hundred and fifty percent (150%) of the cost of continuation coverage during the additional eleven (11) months of continuation coverage. In the event the Social Security Administration makes a final determination that the individual is no longer disabled, the individual must provide notice of that final determination no later than thirty (30) days after the later of:

(A.) The date of the final determination by the Social Security Administration; or(B.) The date on which the individual is furnished with a copy of this Plan Document.

END OF CONTINUATION

Continuation of coverage under this provision will end on the earliest of the following dates:

1. Eighteen (18) months (or twenty-nine (29) months if continuation coverage is extended due to certain disability status as described above) from the date continuation began because of an 18-Month Qualifying Event or the last day of leave under the Family and Medical Leave Act of 1993.

2. Twenty-four (24) months from the date continuation began because of the call-up to military duty.

3. Thirty-six (36) months from the date continuation began for dependents whose coverage ended because of the death of the employee, divorce or legal separation from the employee, or the child's loss of dependent status.

4. The end of the period for which contributions are paid if the covered person fails to make a payment by the date specified by the plan administrator (or its designee). In the event continuation coverage is terminated for this reason, the individual will receive a notice describing the reason for the termination of coverage, the effective date of termination, and any rights the individual may have under this Plan or under applicable law to elect an alternative group or individual coverage, such as a conversion right. This notice is referred to below as an "Early Termination Notice."

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5. The date coverage under this Plan ends and the employer offers no other group health benefit plan. In the event continuation coverage is terminated for this reason, the individual will receive an Early Termination Notice.

6. The date the covered person first becomes entitled, after the date of the covered person's original election of continuation coverage, to Medicare benefits under Title XVIII of the Social Security Act. In the event continuation coverage is terminated for this reason, the individual will receive an Early Termination Notice.

7. The date the covered person first becomes covered under any other employer’s group health plan after the original date of the covered person's election of continuation coverage, but only if such group health plan does not have any exclusion or limitation that affects coverage of the covered person’s pre-existing condition. In the event continuation coverage is terminated for this reason, the individual will receive an Early Termination Notice.

8. For the spouse or dependent child of a covered employee who becomes entitled to Medicare prior to the spouse’s or dependent’s election for continuation coverage, thirty-six (36) months from the date the covered employee becomes entitled to Medicare.

9. Retirees, and widows or widowers of retirees who died before substantial elimination of coverage within one (1) year of the employer's bankruptcy, are entitled to lifetime continuation coverage. However, if a retiree dies after substantial elimination of coverage within one (1) year of the employer's bankruptcy, the surviving spouse and dependent children may only elect an additional thirty-six (36) months of continuation coverage after the death.

SPECIAL RULES REGARDING NOTICES

1. Any notice required in connection with continuation coverage under this Plan must, at minimum, contain sufficient information so that the plan administrator (or its designee) is able to determine from such notice the employee and dependent(s) (if any), the qualifying event or disability, and the date on which the qualifying event occurred.

2. In connection with continuation coverage under this Plan, any notice required to be provided by any individual who is either the employee or a dependent with respect to the qualifying event may be provided by a representative acting on behalf of the employee or the dependent, and the provision of the notice by one individual shall satisfy any responsibility to provide notice on behalf of all related eligible individuals with respect to the qualifying event.

3. As to an Election Notice, Non-Eligibility Notice or Early Termination Notice:

a. A single notice addressed to both the employee and the spouse will be sufficient as to both individuals if, on the basis of the most recent information available to the Plan, the spouse resides at the same location as the employee; and

b. A single notice addressed to the employee or the spouse will be sufficient as to each dependent child of the employee if, on the basis of the most recent information available to the Plan, the dependent child resides at the same location as the individual to whom such notice is provided.

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PRE-EXISTING CONDITIONS

In the event that a covered person becomes eligible for coverage under another employer-sponsored group health plan, and that group health plan has an applicable exclusion or limitation regarding coverage of the covered person’s pre-existing condition, the covered person’s continuation coverage under the Plan will not be affected by enrollment under that other group health plan. This Plan shall be primary payer for the covered expenses that are excluded or limited under the other employer sponsored group health plan and secondary payer for all other expenses.

MILITARY MOBILIZATION

If an employee is called for active duty by the United States Armed Services (including the Coast Guard, the National Guard or the Public Health Service), the employee and the employee's dependent may continue their health coverages, pursuant to the Uniformed Services Employment and Reemployment Rights Act (USERRA).

When the leave is less than thirty-one (31) days, the employee and the employee's dependent may not be required to pay more than the employee's share, if any, applicable to that coverage. If the leave is thirty-one (31) days or longer, then the plan administrator (or its designee) may require the employee and the employee's dependent to pay no more than one hundred and two percent (102%) of the full contribution.

The maximum length of the continuation coverage required under the Uniformed Services Employment and Reemployment Rights Act (USERRA) is the lesser of:

1. Twenty-four (24) months beginning on the day that the leave commences, or

2. A period beginning on the day that the leave began and ending on the day after the employee fails to return to employment within the time allowed.

The period of continuation coverage under USERRA will be counted toward any continuation coverage period concurrently available under COBRA. Upon return from active duty, the employee and the employee's dependent will be reinstated without pre-existing conditions exclusions or a waiting period, regardless of their election of COBRA continuation coverage.

PLAN CONTACT INFORMATION

Questions concerning this Plan, including any available continuation coverage, can be directed to the plan administrator (or its designee).

ADDRESS CHANGES

In order to help ensure the appropriate protection of rights and benefits under this Plan, covered persons should keep the plan administrator (or its designee) informed of any changes to their current addresses.

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MEDICAL/VISION CLAIM FILING PROCEDURE

A “Pre-service claim” is a claim for a Plan benefit that is subject to the prior certification rules, as described in the section below, Pre-service claim Procedure below. All other claims for Plan benefits are “Post-Service Claims” and are subject to the rules described in Post-Service Claim Procedure.

POST-SERVICE CLAIMS PROCEDURE

FILING A CLAIM

1. Claims should be submitted to the claims processor at the address noted below:

CoreSource, Inc.Post Office Box 8215Little Rock, AR 72221-8215

The date of receipt will be the date the claim is received by the claims processor.

2. All claims submitted for benefits must contain all of the following:

a. Name of patientb. Patient’s date of birth.c. Name of employee.d. Address of employee.e. Name of employer and group number.f. Name, address and tax identification number of provider.g. Employee Social Security Number. h. Date of service.i. Diagnosis (applies to medical claims ONLY))j. Description of service and procedure number.k. Charge for service.l. The nature of the accident, injury or illness being treated.

3. Claims submitted for prescriptions must contain all of the following:

a. Name of patient.b. Name of employee.c. Name of employer and group number.d. Employee Social Security Number. e. Name and address of the pharmacy.f. Date of purchase.g. The cost.h. Prescription number and name of prescription drug.i. Prescription reference number.

Cash register receipts, credit card copies, labels from containers and cancelled checks are not acceptable.

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4. Properly completed claims not submitted by March 31st of the year following the date of service will not be a covered service and will be denied.

The covered person may ask the health care provider to submit the claim directly to the claims processor, or the covered person may submit the bill with a claim form. However, it is ultimately the covered person’s responsibility to make sure the claim for benefits has been filed.


The covered person may provide the plan administrator or their designee with a written authorization for an authorized representative to represent and act on behalf of a covered person and consent to the release of information related to the covered person to the authorized representative with respect to a claim for benefits or an appeal. Authorization forms may be obtained from the Human Resource Department.

NOTICE OF CLAIM

A claim for benefits should be submitted to the claims processor within ninety (90) calendar days after the occurrence or commencement of any services by the Plan, or as soon thereafter as reasonably possible.

Failure to file a claim within the time provided shall not invalidate or reduce a claim for benefits if: (1) it was not reasonably possible to file a claim within that time; and (2) that such claim was furnished as soon as possible, but no later than one (1) year after the loss occurs or commences, unless the claimant is legally incapacitated.

Notice given by or on behalf of a covered person or his beneficiary, if any, to the plan administrator or to any authorized agent of the Plan, with information sufficient to identify the covered person, shall be deemed notice of claim.

TIMEFRAME FOR BENEFIT DETERMINATION

After a completed claim has been submitted to the claims processor, and no additional information is required, the claims processor will generally complete its determination of the claim within thirty (30) calendar days of receipt of the completed claim unless an extension is necessary due to circumstances beyond the Plan’s control.

After a completed claim has been submitted to the claims processor, and if additional information is needed for determination of the claim, the claims processor will provide the covered person (or authorized representative) with a notice detailing information needed. The notice will be provided within thirty (30) calendar days of receipt of the completed claim and will state the date as of which the Plan expects to make a decision. The covered person will have forty-five (45) calendar days to provide the information requested, and the Plan will complete its determination of the claim within fifteen (15) calendar days of receipt by the claims processor of the requested information. Failure to respond in a timely and complete manner will result in the denial of benefit payment.

NOTICE OF BENEFIT DENIAL

If the claim for benefits is denied, the plan administrator or their designee shall provide the covered person or authorized representative with a written Notice of Benefit Denial within the timeframes described immediately above.

The Notice of Benefit Denial shall include an explanation of the denial, including:

1. The specific reasons for the denial.2. Reference to the Plan provisions on which the denial is based.

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3. A description of any additional material or information needed and an explanation of why such material or information is necessary.

4. A description of the Plan’s claim appeal procedure and applicable time limits.5. A statement that if the covered person’s appeal (Refer to Appealing a Denied Claim below) is denied, the

covered person has the right to bring a civil action under section 502 (a) of the Employee Retirement Income Security Act of 1974.

6. If an internal rule, guideline, protocol or other similar criterion was relied upon, the Notice of Benefit Denial will contain either:a. A copy of that criterion, orb. A statement that such criterion was relied upon and will be supplied free of charge, upon request.

7. If denial was based on medical necessity, experimental/investigational treatment or similar exclusion or limit, the Plan will supply either:a. An explanation of the scientific or clinical judgment, applying the terms of the Plan to the covered

person’s medical circumstances, orb. A statement that such explanation will be supplied free of charge, upon request.

APPEALING A DENIED POST-SERVICE CLAIM

The “named fiduciary” for purposes of an appeal of a denied Post-Service claim, as described in U. S. Department of Labor Regulations 2560.503-1 (issued November 21, 2000), is the claims processor.

A covered person, or the covered person’s authorized representative, may request a review of a denied claim by making written request to the named fiduciary within one hundred eighty (180) calendar days from receipt of notification of the denial and stating the reasons the covered person feels the claim should not have been denied.


1. The covered person has the right to submit documents, information and comments.2. The covered person has the right to access, free of charge, relevant information to the claim for benefits.3. The review takes into account all information submitted by the covered person, even if it was not

considered in the initial benefit determination.4. The review by the named fiduciary will not afford deference to the original denial.5. The named fiduciary will not be:


6. If original denial was, in whole or in part, based on medical judgment:a. The named fiduciary will consult with a professional provider who has appropriate training and

experience in the field involving the medical judgment; andb. The professional provider utilized by the named fiduciary will be neither:

(i.) An individual who was consulted in connection with the original denial of the claim, nor(ii.) A subordinate of any other professional provider who was consulted in connection with

the original denial.7. If requested, the named fiduciary will identify the medical or vocational expert(s) who gave advice in

connection with the original denial, whether or not the advice was relied upon.

NOTICE OF BENEFIT DETERMINATION ON APPEAL

The plan administrator or their designee shall provide the covered person (or authorized representative) with a written notice of the appeal decision within sixty (60) calendar days of receipt of a written request for the appeal.

If the appeal is denied, the Notice of Appeal Decision will contain an explanation of the Decision, including:

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1. The specific reasons for the denial.2. Reference to specific Plan provisions on which the denial is based.3. A statement that the covered person has the right to access, free of charge, relevant information to the

claim for benefits.4. A statement that if the covered person’s appeal is denied, the covered person has the right to bring a civil

action under section 502 (a) of the Employee Retirement Income Security Act of 1974.5. If an internal rule, guideline, protocol or other similar criterion was relied upon, the Notice of Appeal Deci-

sion will contain either:a. A copy of that criterion, orb. A statement that such criterion was relied upon and will be supplied free of charge, upon request.

6. If the denial was based on medical necessity, experimental/investigational treatment or similar exclusion or limit, the Plan will supply either:a. An explanation of the scientific or clinical judgment, applying the terms of the Plan to the

claimant’s medical circumstances, orb. A statement that such explanation will be supplied free of charge, upon request.

FOREIGN CLAIMS

In the event a covered person incurs a covered expense in a foreign country, the covered person shall be responsible for providing the following information to the claims processor before payment of any benefits due are payable.

1. The claim form, provider invoice and any documentation required to process the claim must be submitted in the English language.

2. The charges for services must be converted into U.S. dollars.

3. A current published conversion chart, validating the conversion from the foreign country’s currency into U.S. dollars, must be submitted with the claim.

PRE-SERVICE CLAIMS PROCEDURES

HEALTH CARE MANAGEMENT

Health Care Management is the process of evaluating whether proposed services, supplies or treatments are medically necessary and appropriate to help ensure quality, cost-effective care.

Certification of medical necessity and appropriateness by the Health Care Management Organization does not establish eligibility under the Plan nor guarantee benefits.

FILING A PRE-CERTIFICATION CLAIM

All inpatient admissions are to be certified by the Health Care Management Organization. For non-urgent care, the covered person or their authorized representative must call the Health Care Management Organization at least fifteen (15) calendar days prior to initiation of services. If the Health Care Management Organization is not called at least fifteen (15) calendar days prior to initiation of services for non-urgent care, benefits may be reduced. For urgent care, the covered person or their authorized representative must call the Health Care Management Organization within forty-eight (48) hours or the next business day after the initiation of services.

Covered persons shall contact the Health Care Management Organization by calling:

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1-866-292-8108

When a covered person (or authorized representative) calls the Health Care Management Organization, he or she should be prepared to provide all of the following information:

1. Employee’s name, address, phone number and Social Security Number.2. Employer’s name.3. If not the Employee, the patient’s name, address, phone number.4. Admitting physician’s name and phone number.5. Name of facility.6. Date of admission or proposed date of admission.7. Condition for which patient is being admitted.

Group health plans generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than forty-eight (48) hours following a normal vaginal delivery, or less than ninety-six (96) hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than forty-eight (48) hours (or ninety-six (96) hours as applicable). In any case, plans may not, under federal law, require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods.

However, hospital maternity stays in excess of forty-eight (48) or ninety-six (96) hours as specified above must be certified.

If the covered person (or authorized representative) fails to contact the Health Care Management Organization prior to the hospitalization and within the timelines detailed above, and/or the Health Care Management Organization declines to grant the full precertification requested, the amount of benefits that the Plan may pay for expenses incurred may be reduced by $200. (Refer to Post-Service Claims Procedure discussion above.)


The covered person may provide the plan administrator or their designee with a written authorization for an authorized representative to represent and act on behalf of a covered person and consent to release of information related to the covered person to the authorized representative with respect to a claim for benefits or an appeal. Authorization forms may be obtained from the Human Resource Department.

TIMEFRAME FOR PRE-SERVICE CLAIM DETERMINATION

A. In the event the Plan receives from the covered person (or authorized representative) a communication that fails to follow the pre-certification procedure as described above but communicates at least the name of the covered person, a specific medical condition or symptom, and a specific treatment, service or product for which prior approval is requested, the covered person (or the authorized representative) will be orally notified (and in writing if requested), within five (5) calendar days of the failure of the proper procedure to be followed.

B. After a completed pre-certification request for non-urgent care has been submitted to the Plan, and if no additional information is required, the Plan will generally complete its determination of the claim within a reasonable period of time, but no later than fifteen (15) calendar days from receipt of the request.

C. After a pre-certification request for non-urgent care has been submitted to the Plan, and if an extension of time to make a decision is necessary due to circumstances beyond the control of the Plan, the Plan will, within fifteen (15) calendar days from receipt of the request, provide the covered person (or authorized

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representative) with a notice detailing the circumstances and the date by which the Plan expects to render a decision. If the circumstances include a failure to submit necessary information, the notice will specifically describe the needed information. The covered person will have forty-five (45) calendar days to provide the information requested, and the Plan will complete its determination of the claim no later than fifteen (15) calendar days after receipt by the Plan of the requested information. Failure to respond in a timely and complete manner will result in a denial.

CONCURRENT CARE CLAIMS

If an extension beyond the original certification is required, the covered person (or authorized representative) shall call the Health Care Management Organization for continuation of certification.

A. If a covered person (or authorized representative) requests to extend benefits for a previously approved hospitalization or an ongoing course of treatment, and;1. The request involves non-urgent care, then the extension request must be processed within fifteen

(15) calendar days after the request was received.2. The inpatient admission or ongoing course of treatment involves urgent care, and

a. The request is received at least twenty-four (24) hours before the scheduled end of a hospitalization or course of treatment, then the request must be ruled upon and the covered person (or authorized representative) notified as soon as possible but no later than twenty-four (24) hours after the request was received; or

b. The request is received less than twenty-four (24) hours before the scheduled end of the hospitalization or course of treatment, then the request must be ruled upon and the covered person (or authorized representative) notified no later than seventy-two (72) hours after the request was received.

If the Health Care Management Organization determines that benefits for the hospital stay or course of treatment should be decreased or terminated before the end of the fixed number of days and/or treatments, or the fixed time period that was previously approved, then the Health Care Management Organization shall:

A. Notify the covered person of the proposed change, andB. Allow the covered person to file an appeal and obtain a decision, before the end of the fixed number of

days and/or treatments, or the fixed time period that was previously approved.

If, at the end of previously approved benefits for a hospitalization or course of treatment, the Health Care Management Organization determines that continued confinement is no longer medically necessary, additional days will not be certified. (Refer to Appealing a Denied Pre-Service Claim discussion below.) NOTICE OF PRE-SERVICE DENIAL

If a pre-certification request is denied in whole or in part, the plan administrator or their designee shall provide the covered person (or authorized representative) with a written Notice of Pre-Service Denial within the timeframes above.

The Notice of Pre-Service Denial shall include an explanation of the denial, including:

1. The specific reasons for the denial.2. Reference to the Plan provisions on which the denial is based.3. A description of any additional material or information needed and an explanation of why such material or

information is necessary.4. A description of the Plan’s claim appeal procedure and applicable time limits.

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5. A statement that if the covered person’s appeal (Refer to Appealing a Denied Pre-Service Claim below) is denied, the covered person has the right to bring a civil action under section 502 (a) of the Employee Retirement Income Security Act of 1974.

6. If an internal rule, guideline, protocol or other similar criterion was relied upon, the Notice of Benefit De-nial will contain either:a. A copy of that criterion, orb. A statement that such criterion was relied upon and will be supplied free of charge, upon request.

7. If denial was based on medical necessity, experimental/investigational treatment or similar exclusion or limit, the Plan will supply either:a. An explanation of the scientific or clinical judgment, applying the terms of the Plan to the covered

person’s medical circumstances, orb. A statement that such explanation will be supplied free of charge, upon request.

APPEALING A DENIED PRE-SERVICE CLAIM

The named fiduciary for purposes of an appeal of a Pre-service claim, as described in U. S. Department of Labor Regulations 2560.503-1 (issued November 21, 2000), is the claims processor. A covered person (or authorized representative) may request a review of a denied claim by making a written request to the named fiduciary within one hundred eighty (180) calendar days from receipt of notification of the denial and stating the reasons the covered person feels the claim should not have been denied. If the covered person (or authorized representative) wishes to appeal the denial when the services in question have already been rendered, such an appeal will be considered as a separate Post-Service Claim. (Refer to Post-Service Claims Procedure discussion above.)


1. The covered person has a right to submit documents, information and comments.2. The covered person has the right to access, free of charge, relevant information to the claim for benefits.3. The review takes into account all information submitted by the covered person, even if it was not

considered in the initial benefit determination.4. The review by the named fiduciary will not afford deference to the original denial.5. The named fiduciary will not be:


6. If original denial was, in whole or in part, based on medical judgment, a. The named fiduciary will consult with a professional provider who has appropriate training and

experience in the field involving the medical judgment.b. The professional provider utilized by the named fiduciary will be neither:

i. An individual who was consulted in connection with the original denial of the claim, norii. A subordinate of any other Professional Provider who was consulted in connection with

the original denial.7. If requested, the named fiduciary will identify the medical or vocational expert(s) who gave advice in

connection with the original denial, whether or not the advice was relied upon.

NOTICE OF PRE-SERVICE DETERMINATION ON APPEAL

The plan administrator or their designee shall provide the covered person (or authorized representative) with a written Notice of Appeal Decision as soon as possible, but not later than thirty (30) calendar days from receipt of the appeal.

If the appeal is denied, the Notice of Appeal Decision will contain an explanation of the decision, including:

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1. The specific reasons for the denial.2. Reference to specific Plan provisions on which the denial is based.3. A statement that the covered person has the right to access, free of charge, relevant information to the

claim for benefits.4. A statement that if the covered person’s appeal is denied, the covered person has the right to bring a civil

action under section 502 (a) of the Employee Retirement Income Security Act of 1974.5. A statement that the covered person has the right to access, free of charge, information about the voluntary

appeal process.6. If an internal rule, guideline, protocol or other similar criterion was relied upon, the Notice of Appeal Deci-

sion will contain either:a. A copy of that criterion, orb. A statement that such criterion was relied upon and will be supplied free of charge, upon request.

7. If the denial was based on medical necessity, experimental/investigational treatment or similar exclusion or limit, the Plan will supply either:a. An explanation of the scientific or clinical judgment, applying the terms of the Plan to the

claimant’s medical circumstances, orb. A statement that such explanation will be supplied free of charge, upon request.

CASE MANAGEMENT

In cases where the covered person’s condition is expected to be or is of a serious nature, the Health Care Management Organization may arrange for review and/or case management services from a professional qualified to perform such services. The plan administrator shall have the right to alter or waive the normal provisions of this Plan when it is reasonable to expect a cost-effective result without a sacrifice to the quality of care.

In addition, the Health Care Management Organization may recommend (or change) alternative:

1. methods of medical care or treatment;2. equipment; or3. supplies

that differ from the medical care or treatment, equipment or supplies that are considered covered expenses under the Plan.

The recommended alternatives will be considered as covered expenses under the Plan provided the expenses can be shown to be viable, medically necessary, and are included in a written case management report or treatment plan proposed by the Health Care Management Organization.

Case management will be determined on the merits of each individual case, and any care or treatment provided will not be considered as setting any precedent or creating any future liability with respect to that covered person or any other covered person.

SPECIAL DELIVERY PROGRAM

“Special Delivery” is a voluntary program for expectant mothers offering prenatal information, pre-screening for pregnancy related risks and information or preparation for childbirth. This program is designed to identify potential high-risk mothers, as well as help ensure a safer pregnancy for both mother and baby.

Expectant mothers who decide to participate in the “Special Delivery” Program will have access to a twenty-four (24) hour toll-free “babyline” which is staffed by obstetrical nurses and will also have a series of four (4) books called “Trimester.”

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An expectant mother may participate in this program by calling the number shown on her identification card and asking for a “Special Delivery” nurse. If possible, she should call during the first three (3) months of her pregnancy in order to receive the full benefits of this program.

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DENTAL CLAIM FILING PROCEDURE

DENTAL CLAIMS

Dental Claims must be filed by Covered Person or Covered Person’s authorized representative with DDAR within twelve (12) months after completion of dental treatment for which dental benefits are payable. Any Dental Claim filed after this period will be denied.

Claims should be submitted to the Claims Processor at the address noted below:

Delta Dental of Arkansas (DDAR)c/o CoreSource, Inc.P.O. Box 15965North Little Rock, AR 72231

The date of receipt will be the date the claim is received by the Claims Processor.

FILING CLAIMS/PARTICIPATING DENTISTS

Participating dentists will complete and submit the dental claim form for covered person at no charge. Participating dentists may ask covered person to fill out the patient section of the dental claim form, which includes the covered employee’s name, social security number (SSN), and address, the covered person’s name, date of birth, and relationship to covered employee; full-time student information, if dependent; and coordination of benefits information, if applicable.

FILING CLAIMS/NON-PARTICIPATING DENTISTS

If the covered person visits a non-participating dentist, the covered person may be required to complete the dental claim form or pay a service charge. The patient section of the dental claim form, which includes the covered employee’s name, social security number (SSN), and address, the covered person’s name, date of birth, and relationship to covered employee; full-time student information, if dependent; and coordination of benefits information, if applicable.

Covered person will also be responsible for ensuring the non-participating dentist completes the dentist and the Diagnostic (TREATMENT) Sections of the dental claim form. The dentist Section includes the dentist’s name, address, SSN or TIN number, license number, and phone number. The dentist must also indicate whether x-rays are attached and answer questions regarding TREATMENT that is the result of an accident. The dentist must also indicate if dentures, bridges, and crowns are replacements, and if so, the date of prior placement and reason for replacement must be noted.

The Diagnostic Section (TREATMENT) includes services performed (name description and ADA procedure code), including date of service, fee for service, and if applicable, tooth number or letter and tooth surface. For any unusual services, the Remarks Section of the dental claim form must give a brief description. The dental claim form needs to be signed by the dentist who performed the services and by the covered person.

PROCESSING THE CLAIM

If covered person visits a participating dentist, the dental claim will be processed according to the Plan upon receipt. For covered persons who visit a participating dentist, notification of the benefit determination will be sent to the covered person in the form of an Explanation of Benefits, which details by service rendered what the Plan allowed and the covered person’s obligation, if any.

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If covered person visits a non-participating dentist, the covered person will receive a Dental Claim Payment Statement, which will detail by service rendered what the Plan allowed and the covered person’s obligation, if any. The Dental Claim Payment Statement will include a benefit check made payable to the covered person.

INITIAL CLAIM DETERMINATION

If the dental claims processor denies all or a portion of the dental claim, covered person will receive an Explanation of Benefits (for covered persons visiting a participating dentist) or a Dental Claim Payment Statement (for covered persons visiting a non-participating dentist) indicating the reason for the denial. The denial explanation will be printed at the bottom of the page.

The covered person will be notified within thirty (30) days of the receipt of the dental claim by dental claims processor of the benefit determination.

In the case of an urgent care claim, the covered person will be notified within seventy-two (72) hours from the time the dental claim is received by the dental claims processor of the benefit determination.

APPEAL OF DENIED CLAIM

If the dental claims processor has denied a dental claim, covered person may appeal the denial. Both the covered person and dental claims processor must take the following steps to complete an appeal (decision review):

Procedures the claimant must follow:

1. Write to the Dental Claims Processor at the following address: Customer Service Support, Post Office Box 15965, North Little Rock, Arkansas, 72231 within one-hundred eighty (180) days of the date on the notice of covered person’s dental claim denial.

2. State why the dental claim should not have been denied.3. Include the denial notice and any other documents, data information, or comments that claimant believe may

have an influence on the appeal of the dental claim.4. If requested, covered person will receive, free of charge, reasonable access to and copies of all documents,

records, and other information relevant to the denied dental claim.5. For an expedited review of an urgent care claim, the request may be submitted orally (by telephone) or in

writing (by facsimile or another similarly expeditious method).

Procedures Dental Claims Processor must follow for a full and fair appeal:

1. Identify the medical or vocational experts whose advice was obtained and utilized on behalf of dental claims process in connection with the denial, without regard to whether the advice was relied upon in making the benefit determination.

2. Not consider the initial denial in the review.3. Conduct a review that includes one or more of the members of the dental claims processor’s Appeals

Committee (to be determined at the sole discretion of dental claims processor), but in no event will the individual who made the initial dental claim denial, nor the subordinate of that individual be part of the review.

4. Consult a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not consulted initially, nor who is the subordinate of such individual if your denial is based in whole or in part on a medical judgment, including determinations with regard to whether a particular TREATMENT, drug, or other item is experimental, investigational, or not medically necessary or appropriate.

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Procedures Dental Claims Processor must follow to notify covered person of its decision (if adverse):

1. Provide covered person with a notice that includes the following information, to wit:a. The specific reason(s) for the adverse determination.b. Reference to the specific PLAN provision(s) on which the adverse determination is based.c. A statement that covered person is entitled to receive, free of charge, access to and copies of all

information relevant to the dental claim.d. A statement describing any voluntary appeal procedures, if any, and a statement of covered person’s

right to bring an action under section 502 (a) of the Employee Retirement Income Security Act.e. The internal rule that was relied upon in making the adverse determination.f. If adverse determination is based on a medical necessity or experimental treatment, either an

explanation of the scientific or clinical judgment for the determination, or a statement that such explanation will be provided free to charge upon request.

2. Provide covered person with the aforementioned notice within seventy-two (72) hours if the dental claim is an urgent care dental claim.

3. Provide covered person with the aforementioned notice within sixty (60) days if the dental claim is a post-service dental claim.

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COORDINATION OF BENEFITSThe Coordination of Benefits provision is intended to prevent duplication of benefits. It applies when the covered person is also covered by any Other Plan(s). When more than one coverage exists, one plan normally pays its benefits in full, referred to as the primary plan. The Other Plan(s), referred to as secondary plan, pays a reduced benefit. When coordination of benefits occurs, the total benefit payable by all plans will not exceed 100% of "allowable expenses." Only the amount paid by this Plan will be charged against the maximum benefit.

The Coordination of Benefits provision applies whether or not a claim is filed under the Other Plan(s). If another plan provides benefits in the form of services rather than cash, the reasonable value of the service rendered shall be deemed the benefit paid.

DEFINITIONS APPLICABLE TO THIS PROVISION

"Allowable Expenses" means any reasonable, necessary, and customary expenses incurred while covered under this Plan, part or all of which would be covered under this Plan. Allowable Expenses do not include expenses contained in the "Exclusions" sections of this Plan.

When this Plan is secondary, "Allowable Expense" will include any deductible or coinsurance amounts not paid by the Other Plan(s). Additionally, if the primary plan is a closed panel plan and this Plan is not a closed panel plan, this Plan will pay as if it were the primary plan when a covered person uses a non-panel provider, except for emergency services that are paid or provided by the primary plan.

When this Plan is secondary, "Allowable Expense" shall not include any amount that is not payable under the primary plan as a result of a contract between the primary plan and a provider of service in which such provider agrees to accept a reduced payment and not to bill the covered person for the difference between the provider's contracted amount and the provider's regular billed charge.

"Other Plan" means any plan, policy or coverage providing benefits or services for, or by reason of medical, dental or vision care. Such Other Plan(s) do not include flexible spending accounts (FSA), health reimbursement accounts (HRA), health savings accounts (HSA), or individual medical, dental or vision insurance policies. “Other Plan” does not include Tricare, Medicare, Medicaid or a state child health insurance program (CHIP). Such Other Plan(s) may include, without limitation:

1. Group insurance or any other arrangement for coverage for covered persons in a group, whether on an insured or uninsured basis, including, but not limited to, hospital indemnity benefits and hospital reimbursement-type plans;

2. Hospital or medical service organization on a group basis, group practice, and other group prepayment plans or on an individual basis having a provision similar in effect to this provision;

3. A licensed Health Maintenance Organization (HMO);

4. Any coverage for students which is sponsored by, or provided through, a school or other educational institution;

5. Any coverage under a government program and any coverage required or provided by any statute;

6. Group automobile insurance;

7. Individual automobile insurance coverage;

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8. Individual automobile insurance coverage based upon the principles of "No-fault" coverage;

9. Any plan or policies funded in whole or in part by an employer, or deductions made by an employer from a person's compensation or retirement benefits;

10. Labor/management trusteed, union welfare, employer organization, or employee benefit organization plans.

"This Plan" shall mean that portion of the employer's Plan which provides benefits that are subject to this provision.

"Claim Determination Period" means a calendar year or that portion of a calendar year during which the covered person for whom a claim is made has been covered under this Plan.

EFFECT ON BENEFITS

This provision shall apply in determining the benefits for a covered person for each claim determination period for the Allowable Expenses. If this Plan is secondary, the benefits paid under this Plan may be reduced so that the sum of benefits paid by all plans does not exceed 100% of total Allowable Expense.

If the rules set forth below would require this Plan to determine its benefits before such Other Plan, then the benefits of such Other Plan will be ignored for the purposes of determining the benefits under this Plan.

ORDER OF BENEFIT DETERMINATION

Except as provided below in Coordination with Medicare, each plan will make its claim payment according to the first applicable provision in the following list of provisions which determine the order of benefit payment:

1. No Coordination of Benefits ProvisionIf the Other Plan contains no provisions for coordination of benefits, then its benefits shall be paid before all Other Plan(s).

2. Member/DependentThe plan which covers the claimant as a member (or named insured) pays as though no Other Plan existed. Remaining covered expenses are paid under a plan which covers the claimant as a dependent.

3. Dependent Children of Parents not Separated or DivorcedThe plan covering the parent whose birthday (month and day) occurs earlier in the year pays first. The plan covering the parent whose birthday falls later in the year pays second. If both parents have the same birthday, the plan that covered a parent longer pays first. A parent's year of birth is not relevant in applying this rule.

4. Dependent Children of Separated or Divorced ParentsWhen parents are separated or divorced, the birthday rule does not apply, instead:

a. If a court decree has given one parent financial responsibility for the child's health care, the plan of that parent pays first. The plan of the stepparent married to that parent, if any, pays second. The plan of the other natural parent pays third. The plan of the spouse of the other natural parent, if any, pays fourth.

b. In the absence of such a court decree, the plan of the parent with custody pays first. The plan of the stepparent married to the parent with custody, if any, pays second. The plan of the parent without custody pays third. The plan of the spouse of the parent without custody, if any, pays fourth.

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5. Active/InactiveThe plan covering a person as an active (not laid off or retired) employee or as that person's dependent pays first. The plan covering that person as a laid off or retired employee, or as that person's dependent pays second.

6. Limited Continuation of CoverageIf a person is covered under another group health plan, but is also covered under this Plan for continuation of coverage due to the Other Plan's limitation for pre-existing conditions or exclusions, the Other Plan shall be primary.

7. Longer/Shorter Length of CoverageIf none of the above rules determine the order of benefits, the plan covering a person longer pays first. The plan covering that person for a shorter time pays second.

COORDINATION WITH MEDICARE

Individuals may be eligible for Medicare Part A at no cost if they: (i) are age 65 or older, (ii) have been determined by the Social Security Administration to be disabled, or (iii) have end stage renal disease. Participation in Medicare Part B and D is available to all individuals who make application and pay the full cost of the coverage.

1. When an employee becomes entitled to Medicare coverage (due to age or disability) and is still actively at work, the employee may continue health coverage under this Plan at the same level of benefits and contribution rate that applied before reaching Medicare entitlement.

2. When a dependent becomes entitled to Medicare coverage (due to age or disability) and the employee is still actively at work, the dependent may continue health coverage under this Plan at the same level of benefits and contribution rate that applied before reaching Medicare entitlement.

3. If the employee and/or dependent are also enrolled in Medicare (due to age or disability), this Plan shall pay as the primary plan. If, however, the Medicare enrollment is due to end stage renal disease, the Plan’s primary payment obligation will end at the end of the thirty (30) month “coordination period” as provided in Medicare law and regulations. If the employee and/or dependent does not elect Medicare, but is otherwise eligible due to end stage renal disease, benefits will be paid as if Medicare has been elected and this Plan will pay secondary benefits upon completion of the thirty (30) month “coordination period.”

4. Notwithstanding Paragraphs 1 to 3 above, if the employer (including certain affiliated entities that are considered the same employer for this purpose) has fewer than one hundred (100) employees, when a covered dependent becomes entitled to Medicare coverage due to total disability, as determined by the Social Security Administration, and the employee is actively-at-work, Medicare will pay as the primary payer for claims of the dependent and this Plan will pay secondary.

5. If the employee and/or dependent elect to discontinue health coverage under this Plan and enroll under the Medicare program, no benefits will be paid under this Plan. Medicare will be the only payor.

6. For a retiree eligible for Medicare due to age, Medicare shall be the primary payor and this Plan shall be secondary. If the retiree does not elect Medicare, but is otherwise eligible due to age, benefits will be paid as if Medicare has been elected and this Plan will pay secondary benefits.

This section is subject to the terms of the Medicare laws and regulations. Any changes in these related laws and regulations will apply to the provisions of this section.

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LIMITATIONS ON PAYMENTS

In no event shall the covered person recover under this Plan and all Other Plan(s) combined more than the total Allowable Expenses offered by this Plan and the Other Plan(s). Nothing contained in this section shall entitle the covered person to benefits in excess of the total maximum benefits of this Plan during the claim determination period. The covered person shall refund to the employer any excess it may have paid.

RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION

For the purposes of determining the applicability of and implementing the terms of this Coordination of Benefits provision, the Plan may, without the consent of or notice to any person, release to or obtain from any insurance company or any other organization any information, regarding other insurance, with respect to any covered person. Any person claiming benefits under this Plan shall furnish to the employer such information as may be necessary to implement the Coordination of Benefits provision.

FACILITY OF BENEFIT PAYMENT

Whenever payments which should have been made under this Plan in accordance with this provision have been made under any Other Plan, the employer shall have the right, exercisable alone and in its sole discretion, to pay over to any organization making such other payments any amounts it shall determine to be warranted in order to satisfy the intent of this provision. Amounts so paid shall be deemed to be benefits paid under this Plan and, to the extent of such payments, the employer shall be fully discharged from liability.

AUTOMOBILE ACCIDENT BENEFITS

The Plan’s liability for expenses arising out of an automobile accident shall always be secondary to any automobile insurance, irrespective of the type of automobile insurance law that is in effect in the covered person's state of residence. Currently, there are three (3) types of state automobile insurance laws.

1. No-fault automobile insurance laws

2. Financial responsibility laws

3. Other automobile liability insurance laws

No Fault Automobile Insurance Laws. In no event will the Plan pay any claim presented by or on behalf of an employee for lost wages or a covered person for medical benefits that would have been payable under an automobile insurance policy but for an election made by the principal named insured under the automobile policy that reduced covered levels and/or subsequent premium. This is intended to exclude, as a covered expense, an employee's lost wages or a covered person's medical expenses arising from an automobile accident that are payable under an automobile insurance policy or that would have been payable under an automobile insurance policy but for such an election.

1. In the event an employee shall incur lost wages or a covered person incurs medical expenses as a result of injuries sustained in an automobile accident while “covered by an automobile insurance policy,” as an operator of the vehicle, as a passenger, or as a pedestrian, benefits will be further limited to medical expenses, that would in no event be payable under the automobile insurance; provided however that benefits payable due to a required deductible under the automobile insurance policy will be paid by the Plan up to the amount equal to that deductible.

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2. For the purposes of this section the following people are deemed “covered by an automobile insurance policy.”

a. An owner or principal named insured individual under such policy.b. A family member of an insured person for whom coverage is provided under the terms and

conditions of the automobile insurance policy.c. Any other person who, except for the existence of the Plan, would be eligible for medical expense

benefits under an automobile insurance policy.

Financial Responsibility Laws. The Plan will be secondary to any potentially applicable automobile insurance even if the state’s “financial responsibility law” does not allow the Plan to be secondary.

Other Automobile Liability Insurance. If the state does not have a no-fault automobile insurance law or a “financial responsibility” law, the Plan is secondary to automobile insurance coverage or to any other person or entity who caused the accident or who may be liable for the employee’s lost wages or covered person's medical expenses pursuant to the general rule for Subrogation/Reimbursement.

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SUBROGATION/REIMBURSEMENTThe Plan is designed to only pay covered expenses for which payment is not available from anyone else, including any insurance company or another health plan. In order to help a covered person in a time of need, however, the Plan may pay covered expenses that may be or become the responsibility of another person, provided that the Plan later receives reimbursement for those payments (hereinafter called “Reimbursable Payments”).

Therefore, by enrolling in the Plan, as well as by applying for payment of covered expenses, a covered person is subject to, and agrees to, the following terms and conditions with respect to the amount of covered expenses paid by the Plan:

1. Assignment of Rights (Subrogation). The covered person automatically assigns to the Plan any rights the covered person may have to recover all or part of the same covered expenses from any party, including an insurer or another group health program (except flexible spending accounts, health reimbursement accounts and health savings accounts), but limited to the amount of Reimbursable Payments made by the Plan. This assignment includes, without limitation, the assignment of a right to any funds paid by a third party to a covered person or paid to another for the benefit of the covered person. This assignment applies on a first-dollar basis (i.e., has priority over other rights), applies whether the funds paid to (or for the benefit of) the covered person constitute a full or a partial recovery, and even applies to funds actually or allegedly paid for non-medical or dental charges, attorney fees, or other costs and expenses. This assignment also allows the Plan to pursue any claim that the covered person may have, whether or not the covered person chooses to pursue that claim. By this assignment, the Plan’s right to recover from insurers includes, without limitation, such recovery rights against no-fault auto insurance carriers in a situation where no third party may be liable, and from any uninsured or underinsured motorist coverage.

2. Equitable Lien and other Equitable Remedies. The Plan shall have an equitable lien against any rights the covered person may have to recover the same covered expenses from any party, including an insurer or another group health program, but limited to the amount of Reimbursable Payments made by the Plan. The equitable lien also attaches to any right to payment from workers’ compensation, whether by judgment or settlement, where the Plan has paid covered expenses prior to a determination that the covered expenses arose out of and in the course of employment. Payment by workers’ compensation insurers or the employer will be deemed to mean that such a determination has been made.

This equitable lien shall also attach to any money or property that is obtained by anybody (including, but not limited to, the covered person, the covered person’s attorney, and/or a trust) as a result of an exercise of the covered person’s rights of recovery (sometimes referred to as “proceeds”). The Plan shall also be entitled to seek any other equitable remedy against any party possessing or controlling such proceeds. At the discretion of the plan administrator, the Plan may reduce any future covered expenses otherwise available to the covered person under the Plan by an amount up to the total amount of Reimbursable Payments made by the Plan that is subject to the equitable lien.

This and any other provisions of the Plan concerning equitable liens and other equitable remedies are intended to meet the standards for enforcement under the United States Supreme Court’s decision entitled, Great-West Life & Annuity Insurance Co. v. Knudson, 534 US 204 (2002). The provisions of the Plan concerning subrogation, equitable liens and other equitable remedies are also intended to supercede the applicability of the federal common law doctrines commonly referred to as the “make whole” rule and the “common fund” rule.

3. Assisting in Plan’s Reimbursement Activities . The covered person has an obligation to assist the Plan to obtain reimbursement of the Reimbursable Payments that it has made on behalf of the covered person, and to provide the Plan with any information concerning the covered person’s other insurance coverage (whether through automobile insurance, other group health program, or otherwise) and any other person or

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entity (including their insurer(s)) that may be obligated to provide payments or benefits to or for the benefit of the covered person. The covered person is required to (a) cooperate fully in the Plan’s (or any Plan fiduciary’s) enforcement of the terms of the Plan, including the exercise of the Plan’s right to subrogation and reimbursement, whether against the covered person or any third party, (b) not do anything to prejudice those enforcement efforts or rights (such as settling a claim against another party without including the Plan as a co-payee for the amount of the Reimbursable Payments and notifying the Plan), (c) sign any document deemed by the plan administrator to be relevant to protecting the Plan’s subrogation, reimbursement or other rights, and (d) provide relevant information when requested. The term “information” includes any documents, insurance policies, police reports, or any reasonable request by the plan administrator or claims processor to enforce the Plan’s rights.

The plan administrator has delegated to the claims processor for medical/dental/vision claims the right to perform ministerial functions required to assert the Plan's rights with regard to such claims and benefits; however, the plan administrator shall retain discretionary authority with regard to asserting the Plan's recovery rights.

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GENERAL PROVISIONSADMINISTRATION OF THE PLAN

The Plan is administered through the Human Resources Department of the employer. The employer is the plan administrator. The plan administrator shall have full charge of the operation and management of the Plan. The employer has retained the services of an independent claims processor experienced in claims review.

The employer is the named fiduciary of the Plan except as noted herein. The claims processor is the named fiduciary of the Plan for pre-service and post service claim (this may be different if an outside vendor is involved) appeals. As the named fiduciary for appeals, the claims processor maintains discretionary authority to review all denied claims under appeal for benefits under the Plan. The employer maintains discretionary authority to interpret the terms of the Plan, including but not limited to, determination of eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan; any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

APPLICABLE LAW

Except to the extent preempted by other federal law, all provisions of the Plan shall be construed and administered in a manner consistent with the requirements under the laws of the State of Arkansas.

ASSIGNMENT

The Plan will pay benefits under this Plan to the employee unless payment has been assigned to a hospital, physician, or other provider of service furnishing the services for which benefits are provided herein. No assignment of benefits shall be binding on the Plan unless the claims processor is notified in writing of such assignment prior to payment hereunder.

Preferred providers normally bill the Plan directly. If services, supplies or treatment has been received from such a provider, benefits are automatically paid to that provider. The covered person's portion of the negotiated rate, after the Plan's payment, will then be billed to the covered person by the preferred provider.

This Plan will pay benefits to the responsible party of an alternate recipient as designated in a Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN).

BENEFITS NOT TRANSFERABLE

Except as otherwise stated herein, no person other than an eligible covered person is entitled to receive benefits under this Plan. Such right to benefits is not transferable.

CLERICAL ERROR

No clerical error on the part of the employer or claims processor shall operate to defeat any of the rights, privileges, services, or benefits of any employee or any dependent(s) hereunder, nor create or continue coverage which would not otherwise validly become effective or continue in force hereunder. An equitable adjustment of contributions and/or benefits will be made when the error or delay is discovered. However, if more than six (6) months has elapsed prior to discovery of any error, any adjustment of contributions shall be waived. No party shall be liable for the failure of any other party to perform.

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CONFORMITY WITH STATUTE(S)

Any provision of the Plan that is in conflict with statutes that are applicable to this Plan is hereby amended to conform to the minimum requirements of said statute(s).

EFFECTIVE DATE OF THE PLAN

The original effective date of this Plan was August 1, 1995. The effective date of the modifications contained herein is January 1, 2012.

NOTE: The claim benefit plan year is calendar year, January 1st through December 31st.

FRAUD OR INTENTIONAL MISREPRESENTATION

If the covered person or anyone acting on behalf of a covered person makes a false statement on the application for enrollment, or withholds information with intent to deceive or affect the acceptance of the enrollment application or the risks assumed by the Plan, or otherwise misleads the Plan, the Plan shall be entitled to recover its damages, including legal fees, from the covered person, or from any other person responsible for misleading the Plan, and from the person for whom the benefits were provided. Any fraud or intentional misrepresentation of a material fact on the part of the covered person or an individual seeking coverage on behalf of the individual in making application for coverage, or any application for reclassification thereof, or for service thereunder is prohibited and shall render the coverage under the Plan null and void.

FREE CHOICE OF HOSPITAL AND PHYSICIAN

Nothing contained in this Plan shall in any way or manner restrict or interfere with the right of any person entitled to benefits hereunder to select a hospital or to make a free choice of the attending physician or professional provider. However, benefits will be paid in accordance with the provisions of this Plan, and the covered person will have higher out-of-pocket expenses if the covered person uses the services of a nonpreferred provider.

FREE CHOICE OF DENTIST

Neither the Plan Administrator nor the Dental Claims Processor furnishes covered dental services directly. The Dental Claims Processor pays for licensed dentists to provide these services. A covered person may choose any dentist. Covered persons should determine the qualifications of the dentist they select. Participation in the DDAR network is open to all dentists who meet DDAR’s standards and who are licensed in Arkansas unless they have previously had their participation in DDAR terminated. DDAR only controls credentialing in Arkansas. However, there is currently in effect a policy by Delta Dental Association (National), which is applicable to DeltaUSA groups, that requires all Delta Plans to have credentialing. Other states’s credentialing policies are available upon request. Whether a dentist is a Participating or Non-Participating Dentist should not be viewed as a statement about that dentist’s abilities.

Visiting a DDAR participating dentist will result in savings. Participating dentists have agreed to accept DDAR’s fee determination as payment in full. If DDAR’s fee is lower than the dentist’s charge, the dentist cannot bill for the difference for covered services. All dentists who participate in DDAR’s networks agree to fill out and file claims for their patients with DDAR coverage; this means less paperwork for covered persons.

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INCAPACITY

If, in the opinion of the employer, a covered person for whom a claim has been made is incapable of furnishing a valid receipt of payment due him and in the absence of written evidence to the Plan of the qualification of a guardian or personal representative for his estate, the employer may on behalf of the Plan, at his discretion, make any and all such payments to the provider of services or other person providing for the care and support of such person. Any payment so made will constitute a complete discharge of the Plan's obligation to the extent of such payment.

INCONTESTABILITY

All statements made by the employer or by the employee covered under this Plan shall be deemed representations and not warranties. Such statements shall not void or reduce the benefits under this Plan or be used in defense to a claim unless they are contained in writing and signed by the employer or by the covered person, as the case may be. A statement made shall not be used in any legal contest unless a copy of the instrument containing the statement is or has been furnished to the other party to such a contest.

LEGAL ACTIONS

No action at law or in equity shall be brought to recover on the benefits from the Plan prior to the expiration of sixty (60) days after all information on a claim for benefits has been filed and the appeal process has been completed in accordance with the requirements of the Plan. No such action shall be brought after the expiration of two (2) years from the date the expense was incurred, or one (1) year from the date a completed claim was filed, whichever occurs first.

LIMITS ON LIABILITY

Liability hereunder is limited to the services and benefits specified, and the employer shall not be liable for any obligation of the covered person incurred in excess thereof. The liability of the Plan shall be limited to the reasonable cost of covered expenses and shall not include any liability for suffering or general damages.

LOST DISTRIBUTEES

Any benefit payable hereunder shall be deemed forfeited if the plan administrator is unable to locate the covered person to whom payment is due, provided, however, that such benefits shall be reinstated if a claim is made by the covered person for the forfeited benefits within the time prescribed in Claim Filing Procedure.

MEDICAID ELIGIBILITY AND ASSIGNMENT OF RIGHTS

The Plan will not take into account whether an individual is eligible for, or is currently receiving, medical assistance under a State plan for medical assistance as provided under Title XIX of the Social Security Act ("State Medicaid Plan") either in enrolling that individual as a covered person or in determining or making any payment of benefits to that individual. The Plan will pay benefits with respect to such individual in accordance with any assignment of rights made by or on behalf of such individual as required under a State Medicaid plan pursuant to § 1912(a)(1)(A) of the Social Security Act. To the extent payment has been made to such individual under a State Medicaid Plan and this Plan has a legal liability to make payments for the same services, supplies or treatment, payment under the Plan will be made in accordance with any State law which provides that the State has acquired the rights with respect to such individual to payment for such services, supplies or treatment under the Plan.

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PHYSICAL EXAMINATIONS REQUIRED BY THE PLAN

The Plan, at its own expense, shall have the right to require an examination of a person covered under this Plan when and as often as it may reasonably require during the pendency of a claim.

DENTAL CLINICAL EXAMINATION

Before approving a claim, the dental claims processor may obtain from any dentist or hospital such information and records they may require to administer the dental claim. The Plan, at its own expense, may require that a covered person be examined by a dental consultant, retained by the Plan, in or near the covered person’s place of residence.

PLAN IS NOT A CONTRACT

The Plan shall not be deemed to constitute a contract between the employer and any employee or to be a consideration for, or an inducement or condition of, the employment of any employee. Nothing in the Plan shall be deemed to give any employee the right to be retained in the service of the employer or to interfere with the right of the employer to terminate the employment of any employee at any time.

PLAN MODIFICATION AND AMENDMENT

The employer may modify or amend the Plan from time to time at its sole discretion, and such amendments or modifications which affect covered persons will be communicated to the covered persons. Any such amendments shall be in writing, setting forth the modified provisions of the Plan, the effective date of the modifications, and shall be signed by the employer's designee.

Such modification or amendment shall be duly incorporated in writing into the master copy of the Plan on file with the employer, or a written copy thereof shall be deposited with such master copy of the Plan. Appropriate filing and reporting of any such modification or amendment with governmental authorities and to covered persons shall be timely made by the employer.

PLAN TERMINATION

The employer reserves the right to terminate the Plan at any time. Upon termination, the rights of the covered persons to benefits are limited to claims incurred up to the date of termination. Any termination of the Plan will be communicated to the covered persons.

Upon termination of this Plan, all claims incurred prior to termination, but not submitted to either the employer or claims processor within three (3) months of the effective date of termination of this Plan, will be excluded from any benefit consideration.

PRONOUNS

All personal pronouns used in this Plan shall include either gender unless the context clearly indicates to the contrary.

RECOVERY FOR OVERPAYMENT

Whenever payments have been made from the Plan in excess of the maximum amount of payment necessary, the Plan will have the right to recover these excess payments. If the company makes any payment that, according to the terms of the Plan, should not have been made, the Plan may recover that incorrect payment, whether or not it was

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made due to the Company’s own error, from the person or entity to whom it was made or from any other appropriate party.

STATUS CHANGE

If an employee or dependent has a status change while covered under this Plan (i.e. dependent to employee, COBRA to active) and no interruption in coverage has occurred, the Plan will provide continuous coverage with respect to any pre-existing condition limitation, deductible(s), coinsurance and maximum benefit.

TIME EFFECTIVE

The effective time with respect to any dates used in the Plan shall be 12:00 a.m. (midnight) as may be legally in effect at the address of the plan administrator.

WORKERS' COMPENSATION NOT AFFECTED

This Plan is not in lieu of, and does not affect any requirement for, coverage by Workers' Compensation Insurance.

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HIPAA PRIVACY

The following provisions are intended to comply with applicable Plan amendment requirements under Federal regulation implementing Section 264 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

DISCLOSURE BY PLAN TO PLAN SPONSOR

The Plan may take the following actions only upon receipt of a Plan amendment certification:

1. Disclose protected health information to the plan sponsor.2. Provide for or permit the disclosure of protected health information to the plan sponsor by a health

insurance issuer or HMO with respect to the Plan.

USE AND DISCLOSURE BY PLAN SPONSOR

The plan sponsor may use or disclose protected health information received from the Plan to the extent not inconsistent with the provisions of this HIPAA PRIVACY Section or the privacy rule.

OBLIGATIONS OF PLAN SPONSOR

The plan sponsor shall have the following obligations:

1. Ensure that:a. Any agents (including a subcontractor) to whom it provides protected health information received

from the Plan agree to the same restrictions and conditions that apply to the plan sponsor with respect to such information; and

b. Adequate separation between the Plan and the plan sponsor is established in compliance with the requirement in 45 C.F.R. 164.504(f)(2)(iii).

2. Not use or further disclose protected health information received from the Plan, other than as permitted or required by the Plan documents or as required by law.

3. Not use or disclose protected health information received from the Plan:a. For employment-related actions and decisions; or

b. In connection with any other benefit or employee benefit plan of the plan sponsor.

4. Report to the Plan any use or disclosure of the protected health information received from the Plan that is inconsistent with the use or disclosure provided for of which it becomes aware.

5. Make available protected health information received from the Plan, as and to the extent required by the privacy rule:a. For access to the individual;

b. For amendment and incorporate any amendments to protected health information received from the Plan; and

c. To provide an accounting of disclosures.

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6. Make its internal practices, books, and records relating to the use and disclosure of protected health information received from the Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Plan with the privacy rule.

7. Return or destroy all protected health information received from the Plan that the plan sponsor still maintains in any form and retain no copies when no longer needed for the purpose for which the disclosure by the Plan was made, but if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible.

8. Provide protected health information only to those individuals, under the control of the plan sponsor who perform administrative functions for the Plan; (i.e. eligibility, enrollment, payroll deduction, benefit determination, claim reconciliation assistance), and to make clear to such individuals that they are not to use protected health information for any reason other than for Plan administrative functions nor to release protected health information to an unauthorized individual.

9. Provide protected health information only to those entities required to receive the information in order to maintain the Plan (i.e. claim administrator, case management vendor, pharmacy benefit manager, claim subrogation, vendor, claim auditor, network manager, stop-loss insurance carrier, insurance broker/consultant, and any other entity subcontracted to assist in administering the Plan).

10. Provide an effective mechanism for resolving issues of noncompliance with regard to the items mentioned in this provision.

11. Reasonably and appropriately safeguard electronic protected health information created, received, maintained, or transmitted to or by the plan sponsor on behalf of the Plan. Specifically, such safeguarding entails an obligation to:a. Implement administrative, physical, and technical safeguards that reasonably and appropriately

protect the confidentiality, integrity, and availability of the electronic protected health information that the plan sponsor creates, receives, maintains, or transmits on behalf of the Plan;

b. Ensure that the adequate separation as required by 45 C.F.R. 164.504(f)(2)(iii) is supported by reasonable and appropriate security measures;

c. Ensure that any agent, including a subcontractor, to whom it provides this information agrees to implement reasonable and appropriate security measures to protect the information; and

d. Report to the Plan any security incident of which it becomes aware.

EXCEPTIONS

Notwithstanding any other provision of this HIPAA PRIVACY Section, the Plan (or a health insurance issuer or HMO with respect to the Plan) may:

1. Disclose summary health information to the plan sponsor:a. If the plan sponsor requests it for the purpose of:

i. Obtaining premium bids from health plans for providing health insurance coverage under the Plan; or

ii. Modifying, amending, or terminating the Plan;

2. Disclose to the plan sponsor information on whether the individual is participating in the Plan, or is enrolled in or has disenrolled from a health insurance issuer or HMO offered by the Plan;

3. Use or disclose protected health information:a. With (and consistent with) a valid authorization obtained in accordance with the privacy rule;b. To carry out treatment, payment, or health care operations in accordance with the privacy rule; or

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c. As otherwise permitted or required by the privacy rule.

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DEFINITIONSCertain words and terms used herein shall be defined as follows and are shown in bold and italics throughout the document:

Accident

An unforeseen event resulting in injury.

Alternate Recipient

Any child of an employee or their spouse who is recognized in a Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN) which has been issued by any court judgment, decree, or order as being entitled to enrollment for coverage under this Plan.

Ambulatory Surgical Facility

A facility provider with an organized staff of physicians which has been approved by the Joint Commission on the Accreditation of Healthcare Organizations, or by the Accreditation Association for Ambulatory Health, Inc., which:

1. Has permanent facilities and equipment for the purpose of performing surgical procedures on an outpatient basis;

2. Provides treatment by or under the supervision of physicians and nursing services whenever the coveredperson is in the ambulatory surgical facility;

3. Does not provide inpatient accommodations; and

4. Is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician.

Birthing Center

A facility that meets professionally recognized standards and complies with all licensing and other legal requirements that apply.

Chemical Dependency

A physiological or psychological dependency, or both, on a controlled substance and/or alcoholic beverages. It is characterized by a frequent or intense pattern of pathological use to the extent the user exhibits a loss of self-control over the amount and circumstances of use; develops symptoms of tolerance or physiological and/or psychological withdrawal if the use of the controlled substance or alcoholic beverage is reduced or discontinued; and the user's health is substantially impaired or endangered or his social or economic function is substantially disrupted. Diagnosis of these conditions will be determined based on standard DSM-III-R (diagnostic and statistical manual of mental disorders) criteria.

Chiropractic Care

Services as provided by a licensed Chiropractor, M.D., or D.O. for manipulation or manual modalities in the treatment of the spinal column, neck, extremities or other joints, other than for a fracture or surgery.

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Claims Processor

Refer to the Summary Plan Description (SPD) section of this document.

Close Relative

The employee's spouse, children, brothers, sisters, or parents; or the children, brothers, sisters or parents of the employee's spouse.

Coinsurance

The benefit percentage of covered expenses payable by the Plan for benefits that are provided under the Plan. The coinsurance is applied to covered expenses after the deductible(s) have been met, if applicable.

Complications of Pregnancy

A disease, disorder or condition that is diagnosed as distinct from pregnancy, but is adversely affected by or caused by pregnancy. Some examples are:

1. Intra-abdominal surgery (but not elective Cesarean Section).

2. Ectopic pregnancy.

3. Toxemia with convulsions (Eclampsia).

4. Pernicious vomiting (hyperemesis gravidarum).

5. Nephrosis.

6. Cardiac Decompensation.

7. Missed Abortion.

8. Miscarriage.

These conditions are not included: false labor; occasional spotting; rest during pregnancy even if prescribed by a physician; morning sickness; or like conditions that are not medically termed as complications of pregnancy.

Concurrent Care

A request by a covered person or their authorized representative to the Health Care Management Organization prior to the expiration of a covered person’s current course of treatment to extend such treatment OR a determination by the Health Care Management Organization to reduce or terminate an ongoing course of treatment.

Confinement

A continuous stay in a hospital, treatment center, extended care facility, hospice, or birthing center due to an illness or injury diagnosed by a physician.

Copay

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A cost sharing arrangement whereby a covered person pays a set amount to a provider for a specific service at the time the service is provided.

Cosmetic Surgery

Surgery for the restoration, repair, or reconstruction of body structures directed toward altering appearance.

Covered Expenses

Medically necessary services, supplies or treatments that are recommended or provided by a physician, professional provider or covered facility for the treatment of an illness or injury and that are not specifically excluded from coverage herein. Covered expenses shall include specified preventive care services.

Covered Person

A person who is eligible for coverage under this Plan, or becomes eligible at a later date, and for whom the coverage provided by this Plan is in effect.

Custodial Care

Care provided primarily for maintenance of the covered person or which is designed essentially to assist the covered person in meeting his activities of daily living and which is not primarily provided for its therapeutic value in the treatment of an illness or injury. Custodial care includes, but is not limited to: help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self-administration of medications. Such services shall be considered custodial care without regard to the provider by whom or by which they are prescribed, recommended or performed.

Room and board and skilled nursing services are not, however, considered custodial care (1) if provided during confinement in an institution for which coverage is available under this Plan, and (2) if combined with other medically necessary therapeutic services, under accepted medical standards, which can reasonably be expected to substantially improve the covered person's medical condition.

Customary and Reasonable Amount

The fee assessed by a provider of service for services, supplies or treatment which shall not exceed the general level of charges made by others rendering or furnishing such services, supplies or treatment within the area where the charge is incurred and is comparable in severity and nature to the illness or injury. Due consideration shall be given to any medical complications or unusual circumstances which require additional time, skill or experience. The customary and reasonable amount is determined from a statistical review and analysis of the charges for a given procedure in a given area. The term "area" as it would apply to any particular service, supply or treatment means a county or such greater area as is necessary to obtain a representative cross-section of the level of charges. The percentage applicable to this Plan is 90% and is applied to CPT codes or HIAA Code Analysis using MDR or HIAA tables.

Dentist

A Doctor of Dental Medicine (D.M.D.), a Doctor of Dental Surgery (D.D.S.), a Doctor of Medicine (M.D.), or a Doctor of Osteopathy (D.O.), other than a close relative of the covered person, who is practicing within the scope of his license.

Dependent

A dependent is:

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1. The term "spouse" means the spouse of the employee under a legally valid existing marriage between person’s of the opposite sex, unless court ordered separation exists. This also includes a valid marriage entered into in another state between persons of the opposite sex, unless court ordered separation exists.

2. The term "child" means the employee's natural child, stepchild, legally adopted child, child placed for adoption, foster child, and a child for whom the employee or covered spouse has been appointed legal guardian, provided the child is less than twenty-six (26) years of age and is not eligible to enroll in any other employer sponsored group health plan, other than through a parent.

3. An eligible child shall also include any other child of an employee or their spouse who is recognized in a Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN) which has been issued by any court judgment, decree, or order as being entitled to enrollment for coverage under this Plan. Such child shall be referred to as an alternate recipient. Alternate recipients are eligible for coverage regardless of whether the employee elects coverage for himself. An application for enrollment must be submitted to the employer for coverage under this Plan. The employer/plan administrator shall establish written procedures for determining whether a medical child support order is a QMCSO or NMSN and for administering the provision of benefits under the Plan pursuant to a valid QMCSO or NMSN. Within a reasonable period after receipt of a medical child support order, the employer/plan administrator shall determine whether such order is a QMCSO, as defined in Section 609 of ERISA, or a NMSN, as defined in Section 401 of the Child Support Performance and Incentive Act of 1998.

The employer/plan administrator reserves the right, waivable at its discretion, to seek clarification with respect to the order from the court or administrative agency which issued the order, up to and including the right to seek a hearing before the court or agency.

4. A dependent child who was covered under the Plan prior to reaching the maximum age limit of twenty-six (26) years and who lives with the employee, is unmarried, incapable of self-sustaining employment and dependent upon the employee for support due to a mental and/or physical disability, will remain eligible for coverage under this Plan beyond the date coverage would otherwise terminate.

Proof of incapacitation must be provided within thirty-one (31) days of the child's loss of eligibility and thereafter as requested by the employer or claims processor, but not more than once every two (2) years. Eligibility may not be continued beyond the earliest of the following:

a. Cessation of the mental and/or physical disability;b. Failure to furnish any required proof of mental and/or physical disability or to submit to any

required examination.

Every eligible employee may enroll eligible dependents. However, if both the husband and wife are employees, they may choose to have one covered as the employee, and the spouse covered as the dependent of the employee, or they may choose to have both covered as employees. Eligible children may be enrolled as dependents of one spouse, but not both.

For further information regarding eligibility for dependents, refer to Eligibility, Dependent Eligibility.


Medical equipment which:

1. Can withstand repeated use;

2. Is primarily and customarily used to serve a medical purpose;

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3. Is generally not used in the absence of an illness or injury;

4. Is appropriate for use in the home.

All provisions of this definition must be met before an item can be considered durable medical equipment. Durable medical equipment includes, but is not limited to: crutches, wheel chairs, hospital beds, etc.

Effective Date

The date of this Plan or the date on which the covered person's coverage commences, whichever occurs later.

Emergency

An accidental injury, or the sudden onset of an illness where the symptoms are of such severity that the absence of immediate medical attention could reasonably result in:

1. Placing the covered person's life in jeopardy, or

2. Causing other serious medical consequences, or

3. Causing serious impairment to bodily functions, or

4. Causing serious dysfunction of any bodily organ or part.

Employee

An Employee is defined as a Bishop, ministerial member, full-time lay pastor or layperson employed by The United Methodist Church or an Annual Conference, local Church, or an agency or institution of such Church.

You are eligible if you are a:

1. Full-Time Active Employee of participating Annual Conferences, local churches, agencies, or institutions of The United Methodist Church. (Non-Clergy employees who perform active work thirty (30) or more hours per week are considered full-time Employees.)

2. Retired Employee of the above participating groups.

3. Surviving Spouse of a deceased employee who was an active employee at time of death.

A Retired Employee is defined as a former Employee retired by a participating group who is receiving a pension financed by the Employer and covered under the Plan prior to retirement.

Surviving Spouse of a deceased employee of the above participating groups.

A Surviving Spouse is defined as the wife or husband of a deceased Employee of a participating group included under this Plan and covered under the Plan prior to the employee’s death and/or retirement.

Employer

The employer is Arkansas United Methodist Conferences.

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Enrollment Date

A covered person's enrollment date is the first day of any applicable service waiting period or the date of hire.

Essential Health Benefits

Those benefits identified by the U.S. Secretary of Health and Human Services, including benefits for covered expenses incurred for the following services:

1. Ambulatory patient services;2. Emergency Services;3. Hospitalization;4. Maternity and newborn care;5. Mental health and substance use disorder services, including behavioral health treatment (mental and

nervous disorder and chemical dependency);6. Prescription drugs;7. Rehabilitative and habilitative services and devices;8. Laboratory services;9. Preventive and wellness services and chronic disease management;10. Pediatric services, including oral and vision care.

Experimental/Investigational/Investigative

Services, supplies, drugs and treatment which do not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered.

The claims processor, named fiduciary for post-service claim appeals, named fiduciary for pre-service claim appeals, employer/plan administrator, or their designee must make an independent evaluation of the experimental/non-experimental standings of specific technologies. The claims processor, named fiduciary for post-service claim appeals, named fiduciary for pre-service claim appeals, employer/plan administrator or their designee shall be guided by a reasonable interpretation of Plan provisions and information provided by qualified independent vendors who have also reviewed the information provided. The decisions shall be made in good faith and rendered following a factual background investigation of the claim and the proposed treatment. The claims processor, named fiduciary for post-service claim appeals, named fiduciary for pre-service claim appeals, employer/plan administrator or their designee will be guided by the following examples of experimental services and supplies:

1. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or

2. If the drug, device, medical treatment or procedure, was not reviewed and approved by the treating facility’s institutional review board or other body serving a similar function, or if federal law requires such review or approval; or

3. If “reliable evidence” shows that the drug, device, medical treatment or procedure is the subject of on-going Phase I or Phase II clinical trials, is in the research, experimental, study or investigational arm of on-going Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with a standard means of treatment or diagnosis; or

4. If “reliable evidence” shows that prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum

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tolerated dose, its toxicity, its safety, or its efficacy as compared with standard means of treatment or diagnosis.

“Reliable evidence” shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure.

Extended Care Facility

An institution, or distinct part thereof, operated pursuant to law and one which meets all of the following conditions:

1. It is licensed to provide, and is engaged in providing, on an inpatient basis, for persons convalescing from illness or injury, professional nursing services, and physical restoration services to assist covered persons to reach a degree of body functioning to permit self-care in essential daily living activities. Such services must be rendered by a Registered Nurse or by a Licensed Practical Nurse under the direction of a registered nurse.

2. Its services are provided for compensation from its covered persons and under the full-time supervision of a physician or Registered Nurse.

3. It provides twenty-four (24) hour-a-day nursing services.

4. It maintains a complete medical record on each covered person.

5. It is not, other than incidentally, a place for rest, a place for the aged, a place for drug addicts, a place for alcoholics, a place for custodial or educational care, or a place for the care of mental and nervous disorders.

6. It is approved and licensed by Medicare.

This term shall also apply to expenses incurred in an institution referring to itself as a skilled nursing facility, convalescent nursing facility, or any such other similar designation.

Facility

A healthcare institution which meets all applicable state or local licensure requirements.

Full-time

Employees who are regularly scheduled to work not less than thirty (30) hours per work week.

Generic Drug

A prescription drug that is generally equivalent to a higher-priced brand name drug with the same use and metabolic disintegration. The drug must meet all Federal Drug Administration (FDA) bioavailability standards and be dispensed according to the professional standards of a licensed pharmacist or physician and must be clearly designated by the pharmacist or physician as generic.

Health Care Management

A process of evaluating if services, supplies or treatment are medically necessary and appropriate to help ensure cost-effective care.

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Health Care Management Organization

The individual or organization designated by the employer for the process of evaluating whether the service, supply, or treatment is medically necessary. The Health Care Management Organization is CoreSource, Inc.

Home Health Aide Services

Services which may be provided by a person, other than a Registered Nurse, which are medically necessary for the proper care and treatment of a person.

Home Health Care

Includes the following services: private duty nursing, skilled nursing visits, and hospice.

Home Health Care Agency

An agency or organization which meets fully every one of the following requirements:

1. It is primarily engaged in and duly licensed, if licensing is required, by the appropriate licensing authority, to provide skilled nursing and other therapeutic services.

2. It has a policy established by a professional group associated with the agency or organization to govern the services provided. This professional group must include at least one physician and at least one Registered Nurse. It must provide for full-time supervision of such services by a physician or Registered Nurse.

3. It maintains a complete medical record on each covered person.

4. It has a full-time administrator.

5. It qualifies as a reimbursable service under Medicare.

Hospice

An agency that provides counseling and medical services and may provide room and board to a terminally ill covered person and which meets all of the following tests:

1. It has obtained any required state or governmental Certificate of Need approval.

2. It provides service twenty-four (24) hours-per-day, seven (7) days a week.

3. It is under the direct supervision of a physician.

4. It has a Nurse coordinator who is a Registered Nurse.

5. It has a social service coordinator who is licensed.

6. It is an agency that has as its primary purpose the provision of hospice services.

7. It has a full-time administrator.

8. It maintains written records of services provided to the covered person.

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9. It is licensed, if licensing is required.

Hospital

An institution which meets the following conditions:

1. It is licensed and operated in accordance with the laws of the jurisdiction in which it is located which pertain to hospitals.

2. It is engaged primarily in providing medical care and treatment to ill and injured persons on an inpatient basis at the covered person's expense.

3. It maintains on its premises all the facilities necessary to provide for the diagnosis and medical and surgical treatment of an illness or injury; and such treatment is provided by or under the supervision of a physician with continuous twenty-four (24) hour nursing services by or under the supervision of Registered Nurses.

4. It qualifies as a hospital and is accredited by the Joint Commission on the Accreditation of Healthcare Organizations.

5. It must be approved by Medicare.

Under no circumstances will a hospital be, other than incidentally, a place for rest, a place for the aged, or a nursing home.

Hospital shall include a facility designed exclusively for physical rehabilitative services where the covered person received treatment as a result of an illness or injury.

The term hospital, when used in conjunction with inpatient confinement for mental and nervous conditions or chemical dependency, will be deemed to include an institution which is licensed as a mental hospital or chemical dependency rehabilitation and/or detoxification facility by the regulatory authority having responsibility for such licensing under the laws of the jurisdiction in which it is located.

Illness

A bodily disorder, disease, physical sickness, or pregnancy of a covered person.

Immediate Care Center

A facility which is engaged primarily in providing minor emergency and episodic medical care and which has:

1. a board-certified physician, a Registered Nurse (RN) and a registered x-ray technician in attendance at all times;

2. has x-ray and laboratory equipment and life support systems.

An immediate care center may include a clinic located at, operated in conjunction with, or which is part of a regular hospital.

Incurred or Incurred Date

With respect to a covered expense, the date the services, supplies or treatment are provided.

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Injury

A physical harm or disability that is the result of a specific incident caused by external means. The physical harm or disability must have occurred at an identifiable time and place. Injury does not include illness or infection of a cut or wound.

Inpatient

A confinement of a covered person in a hospital, hospice, or extended care facility as a registered bed patient, for twenty-three (23) or more consecutive hours and for whom charges are made for room and board.

Intensive Care

A service that is reserved for critically and seriously ill covered persons requiring constant audio-visual surveillance which is prescribed by the attending physician.

Intensive Care Unit

A separate, clearly designated service area which is maintained within a hospital solely for the provision of intensive care. It must meet the following conditions:

1. Facilities for special nursing care not available in regular rooms and wards of the hospital;

2. Special life saving equipment which is immediately available at all times;

3. At least two beds for the accommodation of the critically ill; and

4. At least one Registered Nurse in continuous and constant attendance twenty-four (24) hours-per-day.

This term does not include care in a surgical recovery room, but does include cardiac care unit or any such other similar designation.

Late Enrollee

A covered person who did not enroll in the Plan when first eligible or as the result of a special enrollment period.

Layoff

A period of time during which the employee, at the employer's request, does not work for the employer, but which is of a stated or limited duration and after which time the employee is expected to return to full-time, active work. Layoffs will otherwise be in accordance with the employer's standard personnel practices and policies.

Leave of Absence

A period of time during which the employee does not work, but which is of stated duration after which time the employee is expected to return to active work.

Maximum Benefit

Any one of the following, or any combination of the following:

1. The maximum amount paid by this Plan for any one covered person during the entire time he is covered by this Plan.

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2. The maximum amount paid by this Plan for any one covered person for a particular covered expense. The maximum amount can be for:

a. The entire time the covered person is covered under this Plan, orb. A specified period of time, such as a calendar year.

3. The maximum number as outlined in the Plan as a covered expense. The maximum number relates to the number of:

a. Treatments during a specified period of time, orb. Days of confinement, orc. Visits by a home health care agency.


Maximum Plan Allowance or MPA

The maximum dental payment allowed under the Plan for the applicable covered dental service(s) provided by the Dentist. The Dental Claims Processor shall have the discretionary authority to determine the MPA.

Medically Necessary (or Medical Necessity)

Service, supply or treatment which is determined by the claims processor, named fiduciary for post-service claims, named fiduciary for pre-service claims, employer/plan administrator or their designee to be:

1. Appropriate and consistent with the symptoms and provided for the diagnosis or treatment of the covered person’s illness or injury and which could not have been omitted without adversely affecting the covered person’s condition or the quality of the care rendered; and

2. Supplied or performed in accordance with current standards of medical practice within the United States; and

3. Not primarily for the convenience of the covered person or the covered person’s family or professional provider; and

4. Is an appropriate supply or level of service that safely can be provided; and

5. Is recommended or approved by the attending professional provider.

The fact that a professional provider may prescribe, order, recommend, perform or approve a service, supply or treatment does not, in and of itself, make the service, supply or treatment medically necessary and the claims processor, named fiduciary for post-service claims, named fiduciary for pre-service claims, employer/plan administrator or its designee, may request and rely upon the opinion of a physician or physicians. The determination of the claims processor, named fiduciary for post-service claims, named fiduciary for pre-service claims, employer/plan administrator or its designee shall be final and binding.

Medicare

The programs established by Title XVIII known as the Health Insurance for the Aged Act, which includes: Part A, Hospital Benefits For The Aged; Part B, Supplementary Medical Insurance Benefits For The Aged; Part C, Miscellaneous provisions regarding both programs; and Part D, Medicare Prescription Drug Benefit, including any subsequent changes or additions to those programs.

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Mental and Nervous Disorder

An emotional or mental condition characterized by abnormal functioning of the mind or emotions. Diagnosis and classifications of these conditions will be determined based on standard DSM-III-R (diagnostic and statistical manual of mental disorders) or the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services.

Named Fiduciary for Post-Service Claim Appeals

Medical Claims—CoreSource, Inc.Dental Claims—Delta Dental of ArkansasPrescription Drug Claims—CareMark

Named Fiduciary for Pre-Service Claim Appeals

Medical Claims—CoreSource, Inc.Dental Claims—Delta Dental of ArkansasPrescription Drug Claims—CareMark

Negotiated Rate

The rate the preferred providers have contracted to accept as payment in full for covered expenses of the Plan.

Network Provider

An organization who selects and contracts with certain hospitals, physicians, and other health care providers to provide covered persons services, supplies and treatment at a negotiated rate.

Nonparticipating Dentist

Any Dentist other than a Participating Dentist.

Nonparticipating Pharmacy

Any pharmacy, including a hospital pharmacy, physician or other organization, licensed to dispense prescription drugs which does not fall within the definition of a participating pharmacy.


A physician, hospital, or other health care provider that does not have an agreement in effect with the Preferred Provider Organization at the time services are rendered.

Nurse

A licensed person holding the degree Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.) or Licensed Vocational Nurse (L.V.N.) who is practicing within the scope of the license.

Outpatient

A covered person shall be considered to be an outpatient if he is treated at:

1. A hospital as other than an inpatient;

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2. A physician's office, laboratory or x-ray facility; or

3. An ambulatory surgical facility; and

The stay is less than twenty-three (23) consecutive hours.

Participating Dentist or Network Provider

A licensed dentist who has contracted with and agreed to abide by the rules and regulations of DDAR or any other organization that is a member of Delta Dental Plans Association, DeltaUSA or its affiliates. A list of current Participating Dentists or Network Providers is available from DDAR or a covered person may access the website at www.deltadentalar.com.

Participating Pharmacy

Any pharmacy licensed to dispense prescription drugs which is contracted within the pharmacy organization.

Pharmacy Organization

The pharmacy organization is CareMark.

Physician

A Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.), other than a close relative of the covered person who is practicing within the scope of his license.

Placed For Adoption

The date the employee assumes legal obligation for the total or partial financial support of a child during the adoption process.

Plan

"Plan" refers to the benefits and provisions for payment of same as described herein. The Plan is the Arkansas United Methodist Conferences Employee Benefit Plan.

Plan Administrator

The plan administrator is responsible for the day-to-day functions and management of the Plan. The plan administrator is the employer.

Plan Sponsor

The Plan sponsor is Arkansas United Methodist Conferences.

Plan Year End

The plan year end is July 31st.

Pre-Determination

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This is an opinion from the Dental Claims Processor as to payments that would be made by the Plan as reasonably necessary for anticipated Dental Treatment of a covered person. The opinion is based upon information forwarded to the Dental Claims Processor. It does not guarantee such payment in that actual payment would also depend on applicable coverage being in effect at the time any such services were rendered. The payment is subject to Plan Dental Deductibles, co-insurance and Dental Maximums. A covered person is not required to seek a pre-determination for any Dental Treatment under the Plan.

Pre-existing Conditions

An illness or injury which existed within six (6) months before the covered person's enrollment date for coverage under this Plan. An illness or injury is considered to have existed when the covered person:

1. Sought or received professional advice for that illness or injury, or

2. Received medical care or treatment for that illness or injury, or

3. Received medical supplies, drugs, or medicines for that illness or injury.

Preferred Provider

A physician, hospital or other health care facility who has an agreement in effect with the Preferred Provider Organization at the time services are rendered.

Preferred Provider Organization

An organization who selects and contracts with certain hospitals, physicians, and other health care providers to provide services, supplies and treatment to covered persons at a negotiated rate.

Pregnancy

The physical state which results in childbirth or miscarriage.

Primary Care Physician (PCP)

A licensed Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) who is a general or family practitioner, pediatrician, OB/GYN or general internist and has contracted with the network to render services, supplies and treatment to covered persons and to assist in managing the care of covered persons.

Privacy Rule

Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulation concerning privacy of individually identifiable health information, as published in 65 Fed. Reg. 82461 (Dec. 28, 2000) and as modified and published in 67 Fed. Reg. 53181 (Aug. 14, 2002).

Professional Provider

A person or other entity licensed where required and performing services within the scope of such license. The covered professional providers include, but are not limited to:

Certified Addictions Counselor

Certified Registered Nurse Practitioner

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Chiropractor

Clinical Laboratory

Dental Hygienist

Dentist

Dietitian

Licensed Counselors

Licensed Social Workers

Nurse (R.N., L.P.N., L.V.N.)

Nurse Practitioner

Occupational Therapist

Ophthalmologist

Optician

Optometrist

Physical Therapist

Physician

Physician’s Assistant

Podiatrist

Psychologist

Respiratory Therapist

Speech Therapist

Qualified Prescriber

A physician, dentist or other health care practitioner who may, in the legal scope of the license, prescribe drugs or medicines.

Required By Law

The same meaning as the term “required by law” as defined in 45 CFR 164.501, to the extent not preempted by other Federal law.

Retiree

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A former employee who retired from service of the employer and has met the Plan's eligibility requirements to continue coverage under the Plan as a retiree. As used in this document, the term employee shall include retirees covered under the Plan.

Relevant Information

Relevant information, when used in connection with a claim for benefits or a claim appeal, means any document, record or other information:

1. Relied on in making the benefit determination; or2. That was submitted, considered or generated in the course of making a benefit determination, whether or

not relied upon; or3. That demonstrates compliance with the duties to make benefit decisions in accordance with plan documents

and to make consistent decisions; or4. That constitutes a statement of policy or guidance for the Plan concerning the denied treatment or benefit

for the covered person’s diagnosis, even if not relied upon.

Retrospective Review

A review by the Health Care Management Organization after the covered person's discharge from hospital confinement to determine if, and to what extent, inpatient care was a covered service.

Room and Board

Room and linen service, dietary service, including meals, special diets and nourishments, and general nursing service. Room and board does not include personal items.

Routine Examination

A comprehensive history and physical examination which would include services as defined in Medical Expense Benefit, Routine Preventive Care/Wellness Benefit.

Semiprivate

The daily room and board charge which a facility applies to the greatest number of beds in it's semiprivate rooms containing two (2) or more beds.

Treatment Center

1. An institution which does not qualify as a hospital, but which does provide a program of effective medical and therapeutic treatment for chemical dependency, and

2. Where coverage of such treatment is mandated by law, has been licensed and approved by the regulatory authority having responsibility for such licensing and approval under the law, or

3. Where coverage of such treatment is not mandated by law, meets all of the following requirements:

a. It is established and operated in accordance with the applicable laws of the jurisdiction in which it is located.

b. It provides a program of treatment approved by the physician.c. It has or maintains a written, specific, and detailed regimen requiring full-time residence and full-

time participation by the covered person.

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d. It provides at least the following basic services:(1) Room and board(2) Evaluation and diagnosis(3) Counseling(4) Referral and orientation to specialized community resources.

Urgent Care

An emergency or an onset of severe pain that cannot be managed without immediate treatment.

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Claims Processor

CoreSource, Inc.PO Box 8215

Little Rock, AR 72221-8215

For Claims Administration:

Local: (501) 221-9905Toll Free: 1-888-604-9397FAX: (501) 221-9302

For Pre-Certification Information:

CORESOURCE, INC.Toll Free: 1-866-292-8108

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Documents

NATIONAL - arumc.orgdocs.arumc.org/finance-and-administration/insurance/20… · Web viewMedicaid Eligibility and Assignment of ... (myopia) and astigmatism ... approval of the